08070029CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACT- =. R T1V'k'ORMA.TId'N.'$"
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Bu1L9WMEENERRITT DR
TBD — TO BE DETERMINED
08070029
OWNER'S NAME:
PERMIT ISSUIl DALE
JOHN & KRISTINE FERGASON
08/20/2008
i;
SANITARY NO. CONTROL NO.
ARCHRECTIENIGINEER:
BUILDING PERMIT INFO
BLDG EIECI PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
lob Description
r 9 (omaocin{
1 hereby affhm Lost 1 em licensed urukr provision of Chaptam
with Semion70(0 of Division 3aftm Bushman and Potesdom c8-s�dmylk....
ADD 641.5SQ & REMDL (E)BDRM&(E) ENTRY WL BE NW
in full forte end eff S
Lkeam Clan Lic.g
;VNG RM& (N)ENTRY; RE—RF APPRX 24SQ & STRUCTURAL
Dale Contract
JT
CHr7ECrS DECLARA
I understand my plans shall be used m public records
Licensed Pofcaiu..I
OWNER -BUILDER DECLARATION
I hereby a man that I am exempt from the Comnamoes Licmm law for the
following mason. (Section 70313, Buss mss and Professions Code: Any City or county
which mquims a permit to commons. Wer, improve, demolish, or repair any structure
prior to its iamnce, also mquims Ne applicant for such permit to Ek a alencd stammem
that he is 0c.nacd poroanto the pnwimrs of the Contractors ucamo Law(Chapmr 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Divkion 3 of IM Business and pofalans Cots) or
$125000
that he k eampt illsonfrourn and the bask for the alle{a l eamai tan. My vkladan of
316 3 0 0 2 6 Number
Occupancy e
P y Ty'P
Seakn 70313 by any mptiant fora permit subjects the applicant to a dvll funky of
not mom than Dae huwnd dollars (5500} -
.
1, as owner of the property, or my employcm with wages as tlmir sok tampeaaton,
will ad the work.and damrocas is out kmaded or Worm! for..[.(Sec.ION, Business
Required Inspections
and Profession Cade The Contractors Liam Taw does Out apply o an owner of
ns
(I P
property who butch ns improaes thereon, and w ha docs ouch work himul r or though bis
colo employee; poNded tut veh impowmou.o rear inu:MN nsoRertil fm sale a,
_
holders, Ne k yes of c fo, tse owner-
ft or i
haw
builder MOl�w to hWo of pvving Nu K tlid not dtu m improve for Purpose of
eno provingthatdidof prove
_
uk.).
'
❑ I. as owner of the property, em eaelwively camVaoing with licensed ontractors o
.1. Lod pmjen (Sec. 70th. Easiness and Po(ealans Code:) The Contractors U.
,
canto law dam not apply to an owomr of prapQty who ILllds or impmW thereon. and,
who contra for such i ajeots wits s onuxtm(s) llcenred pursuant mthe Convenors
Liomm law.
❑ Ismemanplunder Sec. ,B&PCfnsthkmaam
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby affirm anular penalty of perjury, arm of the following declaratonx
I haw and will mainWn • Cc ltiim ,Of Coasem to self-imuo for WortcrsCompan-
makut. as provided for by Section 3700 of the labor Code, for the performuue of tse
wort for which this permit is Wood.
❑ I haw and WIII maintain Wafkora Compensation hINMa, as mgnimd by Section
370().f ft labor Coda, res the perfmanom.f the wart for which Nis pencil is wad.
My Wartrfg);' reps anon unto rria aM Policy nam` am:
Grtiv. Policy No.� ✓w— 'yo
C^ FlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section coed notbecompleterl if toe Acott Is insane hunted do0a t ({100)
or leu)
1 certify that in the perfomhaco of m work for which this permit is wuW. I shall not
cmplay any pcomn In my mmm rW ambecome subject in the Workma'Compenaton
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. afar making this CertiOem: of Exemption, you should
lacome subj= to the Workers Compnuimn pravwom of the Labor Code, you most
forthwith comply with such provisions or this permit shall be deemed mmka
CONSTRUCTION LENDING AGENCY
1 herebya.. that toner. construction knding.geny for the perfurmena of
the work for which this permit Is Issued (Sec. 3097. Civ- C.)
'
Tondos Names
Landers Add^..
I ceNfy that I law resd Inis application and sum the IM show mrorm.uo Is
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comoer. I a{rtr m comply with all city and county onlinamea cod eau lam muting to
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Wilding eomuuction, and hereby mthoto mpmmamsfl v of this city to enter upon the
ahow-mmmoned popery for impaction purposes.
(sac) agree to taw, indemnify and kap harmlea the City of Cupertino against
liabilities, jud{mcnu, cmu and mpenaa which may In any my acom against said Cly
in consequence of ft tint of this permi
APPLICANT U NDS AND L MPLY WITH ALL NOWPOINf
Issued by: Date
SOURCE REGU
��
Re -roofs
Sitnnum of Applian an or Dau
HAZARDOUS MATERIALS DISCLOSURE
Type Of Roof
Wlllthcappiianlorfutuw build] n pent a tom m handle haaNam notal
as defined by the CupeNco Muninp.l . CNlmr 9.13. and tse Haith and Safety
'
Cods. Section 25532(.)7
All roofs shall be inspected to any roofing material being installed.
❑Ym
prior
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or forum building occupant use equipment or deviaa which
h hWill
mardnm air couminan ns a recd by the Day Am Air QualityManagement
all new materials for inspection.
DSW t7
❑Ya
I hew mad the baaNws..data req.W.r s under Chmtm6.95 of thcCalifor-
niaHcaith& SafclyCcdc, Sections 255 25533 md25534. 1 undcumnd thaifthc building
Jam not <
.Cenifaemafoampm
Signature of Applicant Date
All roof coverings to be Class 'W' or better
owocrns.athor'ved '
agent ,,