04020065 CITY OF CUPERTINO . . "`. _ - "' '" ..3 t y '• "°- "'" _ .
BUILDING DIVISION PERMIT Cb RY�CTOR xbki MA"C
BUILDING ADDRESS: ROCKY & DONNA LOWELL PEa ""'04020065
ER'S NAME: PERMIT ISSUE DATE
ROCKY
INE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
( o 0 0 0
LOO LICENSED CONTRACTOR'S DECLARATION
OFF 1 hereby"an that 1 am limned under previsions of Chapmr 9(common'� IOb Description
wire Sendon?IX )of0iAsion3afthe Businnsmd Professions Cade.and my licca is
is full force and affect.
`,Llz uvea.Class Lle.x REVISION- IN HOUSE USE ONLY
�Fppp Date contractor ORIG. #0 20026
q ARCHITECTS DECLARATION
''>. 1 undersand my plans¢hell M uxd as puhiic ucorda
6�
va
Licensed Professional
3 OWNER-BUILDER DECLARATION
EngI hereby allure Not 1 1. exempt Imre She Contractor's hi LiAny O law for the
S❑O following risen.(Section RD L;Business and Professions Code:Any city nr county
iz$ which its its a a permit uance,also re construct,altea impmm,dcmrent t or repair any overate
Ftp^ priomits tensed pursuant to
theres prevision o for such Contrarmitm Riese signedmoderated
p Q part he is licensed ptmtanae the previsions of She Contractor's lJLensC 12W(Chapter Sq.Ft.Floor Area ValuationO
y $ (commencing with section y000)of Division 3 ofthe Busincuand Professions Coda)ur
t Nat he u exempt de efrom and the basis for Ne alleged eumption.My violation of J
Section 7031.5 by any applicant for a permit subjects me applicam to a civil penalty of APN Number Occupancy Type
not moo than Ron hundred dollars($5007. P Y YP
E]1,as owner of the property.or my employes with wsgca ss their sale compensation, 32645043 . 00
will do the work and the structure is not intended reoffered forsale(Sec.7744,Business
and Pmfecdona Cade:The Contractor's Licem,Law does not apply to an owner of Required Inspections
propeny w ho builds or im proves thercnn,and who does such work himul f or through his
own employees,provided that such improvemenbae notinerided crortered forsele.If,
however,the building or improvement is sold within one yam of completion,the owner
builder will have the burden of proving that he did not Wild or improve for purpose of
ate.).
❑1,as owner of the property,am exclusively convecting with licensed convectors to
construct the project(Sec.1044,Business and Professions Cade:)The Conuactors LI.
cease law don not apply to an owner of property who Wilds or improv thereon,and
who contracts for such projects with a contrutar(G licensed pursuant a the Contramhrs
Lic Law.
1 zroom der ac. B&P C far this..an
am Z.—
S COMPENSATION DEATION
I hereby under penally of perjury one ofthe rationing declarations:
I have and will maintain aCmifintaaf Coasent to ulGinaum for WorkeraCompen-
Station.as provided far by Serum 37W of the labor Code.far the performance of the
work for which this permit at issued.
❑1 have and will maintain Workers Comp osi tion burance,ss required by Section
37ID Of She labor Code,for She perlmmmce of the work for which this persnii s issued.
My Worker's Compeasadhn Insurance comic,and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sn0hn need not W completed lithe permitb forom hundred dollasa(SIM)
nr loss.)
1 certify that in the Performance of the work for which this permit is issued.l shall nut
employ any person in any meaner an as to Inatome subject to dto WorkmCompensation
Laws of Califuren.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to me Worker's Compensation previsions of Use Tabor Code,you mut
.J 0 forthwith comply with such provision or this Permit shell le deemed revoked.
CONMUCT10N LENDING AGENCY
'rr awn I hereby affirm that them is a contraction lending agency for the performance of
a.fir She work fur which this panni,is issued(Sec.3037,Cih,C.)
0 Leadcr's Name
r7 z Landers Md..
U Q I certify that I have mad this application and state that She above information is
Fcorrect.l agree to comply with all city and county ordinances and more laws relating to
U above-mentioned
antl hereby aumorixrpose& tines of this oily to enter upon the
W shave (We)agree toprop
for inspectionniakeep
Lia (We)ague to cove,indemnify and keep harmless w ru
City of Cupertino against
h n
Iiabilities,Judgmcnts,cues end expenswhich may in any way acce against said City
U',Z in cRCA
of the ting of is permit.
" APUNDE 5 ANDS ND WILL COMP Y WITH ALL NON-POINT Issued by: Date
SO9UN
S.
Re-roofs
Si Oreo IiunUCon m Dam
HA2A D s MATERIALS DISCLOSUR Type of Roof
Willmcapplicantor um building emupentere orhantlle harallons rectorial
u Unlined by the Cupeniao Municipal Code.Chapter 9.12,and the Health and Safely
ode.Section 25532(an All roofs shall be inspected prior to any roofing material being installed.
❑Yrs No
Will,he applic Stair building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haaardaus air contaminants in defined by She Bay Area Air Quality Management all new materials for inspection.
District
❑Yn ❑
I have tad the hazardous 4rialsoUquirementsunderClarptorti.95 oflhe Califon
nia Hnith&Sxfciy Codc,Sccdon25 05M� ihjliiy
Mmtmdthatifthc Wilding
dao not currently M1ase nano ma itnuuly the occupant of dw
requircmcn ch mu ma path mste of Occu ane ature ofd licant Date
own r thomcd agent DamI All roof coverings to be Class"B" or better