04040068 CITY OF CUPIiR'I'INO � "*fir "'-k ".'
Buu,nlrvcnrvlslory PERMIT CONIRAC=LHRINEORMATION '
,fes"S.'
BUILDING ADDRESS: PERMIT Ncb 4 0 4 0 0 6 8
29 HYANNISPORT DR
NF.R'S NAME: PERMIT
JOHN & SALLY ADELUS LS6UE D 2 2004
JNE: SANITARY NO. CONTROL NO.
ARCHITECIENOINEER' BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC11
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing
^ with Section)(AM))ofDivisionJoftheBusiness. tlProfcssiomCnac.andmyliccnseis F-9HALE®
J� inmlfcm.rodlfreet. ( REPAIR CRACKE/FOOTING/FOUNDATION
= Liccnu para yf` Lit.4
e Da�c.nt.el.r CONTRACTOR: AVALON STRUCTURE INCAPR $ X2004
A CHITECTS E ATI
-t nderamnd my plana shall W uwd a lic records
_;- Licensedpmfessinnal BUILDING
OWNER-GUILDER DECLARATION
.� I 1 hereby o firm that I am exempt from the Contractor's Liccnu Law for The
D o following reason.(Seedon 7031.5,Business and Profcnd.ns Code:Any city of county
K m which requires a Permit m construct.alter,improve,demolish,or repair any structure
yYi prior to its issuance.also requires the applicant for such Permit to file a signed stammem
££Sa thatheisliccnscdpursuantI.the roviii.nsoftheCmInulm,Lice oce aw(Chapter 9 Sq. FL Floor Area Val ua"500
Y s-� (commencing with Section 7PA(dof Division Jnf the B usinese and Professions Code)
that he is exempt therefrom and the basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of APN Number Occupancy Type
net more than five h.ndmd dollars(s5W). 35611017 . 00
p 1,ter owner of the property,or my employees with wages as their sole compensation,
will do she work,and the structure is not intended or oncrtd for sale(Sec.IDad,Business
and Professions Code:The Contractor's License taw docs not apply to an owner or Required Inspections
property who builds or improves th row n.and who does such work himself or through his
own employms,provided that such improvements arc not intended or offered for sale.If,
however,she building or impmvemend is sold within one year of completion,the owner-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
E]1,as owner of the property,a exclusively concocting with licensed aontractms to
construct the project(Sec.7050,Business and Professions Code:)The Commostori Li
more law dons not apply to an owner or property who builds or improves tremor,and
who contracts for such projects with o conoactor(s)licensed pursuant to the Contractor's
License Law.
❑I sm exempt under See. B k P C for this reason
n
et Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm crater penally of perjury one of the allowing declarations:
have and will maintain a Certificate of Consent to aulf-insure for Worker's Compcn-
n.as provided for by Section 37W of she Labor Code,for the performance of the
work for which this Permit is issued.
nave and will maintain Worker's Compensation Insurance,as required by Section
or the tabor Code,for lie performance of the work for which this Permit is issued.
Worker's Compensation Insurance carrier and Policy nummbeer ara�'5, 1,icrJC/tel &-ti"A L� PgycyNlt e /o S f_'ZW// CERTTFICATEOFEXEMPI NPBtOMWORKERS'
COMPENSATION INSURANCE
This auction need not be completed if the Permit is for one hundred dollars(HOO)
Lt.,.)
1 certify Or,in the performance of the work for which this Permit is issued.I atoll not
employ any probe in any manner an as to become subject to the Workers'Compensation
Laws or California.Data
Applicant
NOTICE TO APPLICANT:If,arcs making this Cedifica¢or Exemption,you should
become subject to the Worker's Compensation provisions N the labor Cede,you must
,J Z forthwith comply with such provisions or this Permit shall W deemed revoked.
zO CONSTRUCTION LENDING AGENCY
'r.(z) I hereby affirm Nm there is a construction Tending agency for the Performance of
g1' 7 the work fur which this Permit is issued(Sec.3097,Civ.C.)
!r] Lender's Name
Under's Address
J O 1 certify that 1 have read this application and sate that the above information is
F' correct 1 agree m comply with all city and county ordinances and state laws relating to
V building construction,and m.hy..,hurt.tep.umatives of Nis city t.under upon the
rabove-mentioned property for impaction purposes.
(Wc)agree re save,indemnify and keep harmless the City Or Cupcnino against
Nliabilities,judgments.culls and expenses which may in any way accrue against mid City y
U inconsequence of the granting of this Permit.
'-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
60 CE REGULATIONS.
v 0 �� �fD
Re-roofs
Signature of pb an on TELOf Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dre a"reom or fuwrc huildin6 Occupant s.nc fir handle hararduus material
u defined by the Cupertino Municipal C.dc.Chapter 9.12.and the Health and Safety
We.Section 255J2(a)7 All roofs shall be inspected prior to any roofing material being installed.
Oyer, ro
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hararduus air contaminants u defined by tW Bay Arca Air Quality Management all new materials for inspection.
Districff ry�'
❑Yes IJP^
1 have read the haraimousmactialsuquiuments under Chapter 6.95 of the Califor.
ria Hcabbi K Safely Cods,Sachs.25515.25577 and25534.I undemund that i(IM Wilding
does not currently have a tenant,that it is my responsibility a nnrly the Occupant Of the
.quire lwhichm.:Ibemetpri.rt issuaceofacenmeate 0.euparcy' Signature of Applicant Date
R All roof coverings to be Class "I3" or better
mho n.ed agnn Dam