04060027 , OF CUPERTINO ^�-+ m.s. ,�^'`°
DING DIVISION I��IZMIT ^�C01�iTItAGTOR�INZ''OTL�IVIATIOr.
AD RE JACK MYERS CONSTRUCTION PERMIT NO 04060027
'S NAM[: PERMIT L6IIEDATE
HARA DEBBIE 1965 COLLEEN DR "4
Eo SANITARY NO. CONTROL NO.
(408) 761-1185
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
j LICENSED CONTRACTOR'S DECLARATION- 76 Description
I hutch,affirm Nn em licensed licensed under Inmost...of Chapsecomm
r 9( encin0Ip
g
n� with Sm1sm701g0af Divlsion3ofdm Bmi rad Profcasiuns Code,andmylimusais
in full tome ercat (� TEAR OFF SHAKE ROOF, SHEF�T,� OF�WITH
j b z License CI Lic. r
Do 2 coram m 50 YEAR COMP
A CHNECTS DEC ON
1 hamramnd my plant shell W used u pun' recnNs
JUN 21- 2004
Licensed Professional
OW NER-BUILOER DECLARATION
+� I hemhy aRrm that 1 am uempr from de Comannr's License law for use
`oo following moon.(Smdun 703 1.5,Business and Professiuu Cade:My city or county BUILDING$ which requires a permit to cnnsrmcL mow
site,Improve,demolish,m repair any ectme `IIS
—�y prior at its ivuance,alsorequires the applicant for such permit m file a signed ainherent
€� that he u licensed pursuent to Ne provisions of the Contractor's Llmnse Law(Chapter 9 Sq. Ft.Floor Area Valuat"000
(commencing with Section 7")of Division 3 of Oc Busimuand Profeviona Code)or
$ Istat k u exempt therefrom and the bolt for dM allegW eumpdon.My violation of
Semon7031,5 by any applicant fora permit subjects the applicant to.civil pchalry of APN Number Occupancy
not mom than five hundred dollen($500). p y Type
35614048 ' 00
❑huownv of the pmpeny,ar my employees with weguu their sole campenu0on,
will do the wo&and the swoon is not intended or offered f...1.(See.7044,Business
and Profnsnou Code:The Contractor's License law does oat apply in an..of Required Inspections
property who bui Ids or im proves thereon,a nd who docs such wak himsel f or through his
own employees.provided Natsuch improvements are nolimended oroffeud forsale.If,
however.the building or improvement is sold within one yev of completion,the owner.
builder will have the Wrden of Proving that he did not Wild ar improve far puryoae of
uleJ.
❑1,as no of de proper y,am udu.ively..=do&with licensed centranms to
construct the project(Sec.70414,Business and Professions Cade:)The Comirmurr't U.
cents Law does not apply man owner of property who Wilda or improves dum rd.and,
who contracts for such projects with acontractoKN licensed punuam m due Comarcuses
Li tie Law.
I are exempt under See. .B h PC far s n
eLAO�41
r Da e
ORKER'S COMP ATION DECLARATION ,
1 he anion under Kul, f perjury one of the following dcel dont:
have
d will maintain a CedifiatMafComenuoself-lasarefa Worker's Compere
don,u provided(car by Section 3700 of the Loan Cade,fm Ne perfarmvce of dre
work for whim this permit Is issued.
❑I bave and will maintain Worker's Compensadon fns atom.u acquired by Section
37Wof the labor Code.for dM performance of the work for which this Permit is issued.
My Wahcls Compensation Insurer¢carrier and Policy number are:
Cartier. Policy No, _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section recd Int weemplered lids:permit is for roc hundred dollars($100)
or later)
1 cuddly that in the Performance of the work for which this Permit u issued.l shall not
employ any pen nymenn rwum esubject mlW Wohcri Campensatlan
Laws Calif r' .D
Applic
NGTTC CAI .aMr makin a enifma a of Exemption,you should
become auhj t t the.We
Compc ren provisions of the labor Code,you must
.J O forthwith c with such provisions this warnit.hall W dcemcd revoked. _
CONSTRUCTION LENDING AGENCY
(-i I hemhy affirm Nat ft.I..conswctinn lending.gency far the performance of
Qi the work far which Ods Permit is issued(Sec.3097,Civ.C.)
0. Q Lenders Name
D z Lender's Add.
vJC 1 codify Net 1 have read Ni.application and soon tho the above inf..too is
($.E cormcL 1 agree m comply with all city cad county ordinances and sate tam rcudng M
C) Wilding construction,and hereby suthones represenutiar of this city m enter upon are
W shove-memioned Property for inspection purposes.
LL (W)agree in cave,indemnify and keep hornless IM City of Cupertino against
i..rA liabilities judgments,toss and expenses which may in my way seems against old City
V z in consequence of the grant of this permit.
APPLICANT UNDER NDS AND ILL COMPLY WITH ALL NON-P INT Issued by: Date
S ou cues
Re-roofs
Si of ApplinHAZARcmr e
HAZARDOUS TEmIALScso DISCLOSURE Type of Roof
Will y dicChisholm
applicant or mfuture al Co aavput d9m orhandlethe
h Health us and Safeal
ty Oncd by the Cupenina Municipal Code.Chapter 9.12,and the HesIN and Safety
.Suction 25532(.)? �t All roofs shall be inspected prior to any roofing material being installed.
❑Yes 9Na
Will the applicant or forum Wilding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
havamnes airir conteumimnu u defined by the Bay Area Air Quality Management all new materials for CllOn.
0Yes \ No
I have mad the Word..s ram ials requirements under Chapter 6.95 of the Califon
n' HcalthhSafnYCode.Secdou25505. 33 and 25534.1 undcrsMM lhuifde Wilding
not curmndy hash a L y ratponsibility m notify lie occupant of Nc V G f/
ryes' cru which mu 'ssu cafeCeodOcaMofRup 6 SI ore of Applicant DaI
o ar.athariytd ager M All gdf coverings to be Class "B"or better