08030086 CITY OF CUPERTINOa�'e�g ��T� �7g,{ err •-'f�'y
BUILDING DIVISION PERMIT s W .LAS?11�R'AWl\Ikx.�'Ofy' A,v
BUIIAING ggDRESS: PERMIT NO.
10�U0 MANN DR PETER' S CONSTRUCTION 08030086
HER'S NAME: - PERMIT ISSUE DATE
AI JACK K AND GLORIA H P 0 BOX 60201 03/25/2008
NE: -(650) 906-8788 SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
upp LICENSED CONTRACTORS DECLARATION
ee I hereby"And that 1 am licensed under patricians of Chapter 9(commencing Job Description
n MLhS 4m7")ofDivicion3ofine Bu6n wdPfofmIona Codc dmylicemeie REV) INSTL NEW BEAM & NEW FOOTING, ORIG#07100157
�y In full forte and oma. p � /
n Z License Cleu LW.• '
3:Fi Dam Contractor
e CHf1ECrSDECLARAM
y 1.torsional my plane shall W used u public ra
� U
yQ
� Licensed Pottcssional
OWNER-BUILDER DECLARATION
g53 1 hereby aRres that 1 am exempt from the Convectors License Law for the
COO following..an.(Section 7031.5,Business and ProfoWam Code:Any city m county
$P's. which acquires a permit In construct,alar,improve,demolish,or repair any structure
Zj, prior An its issuance.Stan requires ft applicant for such permit to file a signed atatomcm -
FFE< Nat he is licensed pursuant toNcProvisions ofineConnector's UccomLaw(Chaplu9 Sq.Ft. Floor Area Valuation
Sg (commcing with Section 700M of Division 3 ofthc Bustneuand ProfeuionSCode)or $0
3 deal heenp exempt therefrom and the basis for dm Winged exemption.My violation of
Section 70313 by any applicant far a Permit subjects me applicant to a civil penalty ofNumber - Occas
not mom man free hundred dollars(SSS). 3 2 6 4 5 010 :CIV' Occupancy Type
Q 1,u awner of the property,m my employee what wage u duirwk eompewdon,
will do the work,and memaccmre prat Wended m effated far We(Sm.7044,Business
and Professiam Cade:Tim Connectors License Law does sat apply m an o'w'ner or Required Inspections
propertywho buiIdsorimpatreamemos,and whodoessuchwork bimeeIfarthan ugh his
own employee,provided thatsuch improvements art oalimanded erelfmad fmsale.If.
however,Ne building or impmrsment I.sold within am year ofcompletion.the owner-
builder will have the burden of proving that M did not build or improve for purpose of
sata.).
Q 1,As miner of me property.am exclusively contracting with Iicamed convenors W
construct me project(Sec.7014.Business and Profusion Code:)The Contractors U.
cone law does not apply he an owner of properly who builds or improve memos,and, .
who convects for such pmjecu with a contractor(s)licensed pursuant to the Conuactoel
Uceue Law.
Q i am esmap,under See ,B AL PC for this moon
Data
WORKER'S COMPENSATION DECLARATION
I hereby amen under pemlty of perjury am of me following dalaratimts:
I haveand will msinW n•CeniO®oaf Conxenl to calf-intim far Workers Compao-
I
u provided fm by Section 3700 of me labor Cade,far W performance of me
work for which this Parrett is issued.
Q I have and will maintain Workers Corepenssumn Insurance,u required by Section
3711D of me Labor Code,far the performance of the work for which this permit is Wood.
My Workers Compere tion more camiu and Polity number are:
Carrier, Polity No.: 'L��/J�f�C� 7
CEIITIFICA OF EK PTION FROM W RK RO E S'
COMPENSATION INSURANCE
(Thu scclkm need not be cam plemd If tie permit Is format hundred dollars($100)
ser less.)
I comfy met in me perfomanee of the were for which this permit's issued.I shall not
employ any Person in any mmrcrso As M became subject to me Workers'Compensation
Law,of Califomh.Dam
Applicant
NOTICE 717 APPUCAND If.after making mit;CenlOcae,of Exemption,you sbouW
become subject to the Women Compensation provision of Lou Labor Code,you muss
.,O forthwithcomply with such pmWsmas or this peamil shall as deemed mated.
'Z
[-+M CONSTRUCTION LENDING AGENCY
I hereby amrm Oat them is a commandant Lending agency for the performance or
(Yi r�
an,work fur which this permit is issued(Sec.309E Civ.C.)
W�Q Lenders Nun.
m7. z Lenders Addrau .
V 0 1 unify mat I have mad this application and mm mu me above information p
Liv H enema I agree to comply with WI city and county ominances and atom Ire missing to —
'0 U building construction,and hereby aummixe representatives of this city to carer upon me
` W above-mentioned property for inspection purposes
(We)agree to save,indemnify and kap healeu the City of CupcAno agent
v.i in liabilitica,judgm.nls.ensu and expenses which may In anyway Aceme agalnl said City
(„)7 in consequenm of the grounding of this permh. r(
rte• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS
Re-roofs
Signature ofimuConmctor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ile applicant or future building aaupanulme arbandle haurdous material
as defined by 0th Cupertino Municipal Code,Chapter 9.13,and me Health and Safety
as sss3
as
z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y
WIII the applicant ar forum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hmamova ale co esom nu u defned by the Bay Area Air Quality Management all new materials for inspection.
vice /
QYe HNu
I haw mad the hmudou7s777TT"``mawdalsmquimmmuunder Chapmr6.95 of the Ci ifor.
seta Health&SafctyC.de,Seetion25505,25533 and25534.I undcutand meifde building
dean not cuneany have a amen mat 11 is my mpemibility to tetify the occupant of me
mptirtrmat which rent boat 'ar isa mofa eNfmatearoccupanry. Signature of Applicant Date
owneroracthadmd,gnrt I Dam' - All roof coverings to be Class'AtA'Gr better