06020002 CITY OF CUPERTINO # '4x9 Y"`> y +' °•x 'k' '�'` ' '`
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION;
BUILDING ADDRESS: PERMIT NO,06020002
7818 ROBINDELL WY
SR'S NAME: PERMIT ISSUE DATE
JAMES & MARILYN HARSHMAN 02/01/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUIMING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 herchy affirm that 1 am Iicemcd under provisions of Chaper 9(commencing P
with Section'I")of DiAsion 3 of de Business and Professiurtc Code.end my licerue u
a inOdircom ndeffect. BATHROOM REMODEL/ADD SKYLIGHT
D�Z Dogma class Carriacou,
As said die DECLARATION SOUTH BAY MARBLE HAS BL #27606 1 QQQEEEssa
5. 1 undersand my plata atoll he used u public rttords
JyU
_; ProfessionalLiccnurMAY �- 1006
OWNER-BUILDER DECLARATION
I I hereby affirm Out I em exempt from the Conuacmr's License law for the
00 following reason.(Scmun 7(n 1.5,Business and Pmfctiom Code:MY city or county
which requires a Permit in consumer.Aber,improve,demolish,or repair any Sharruns all rt
iy prior to its issuance.also rectums theapplicant for such permit to File a signed statement �y
< Nat he isEcamadpursuant otheprovisions orthe comracersumnscLaw(Chapter9 Sq.Ft. Floor Area
Y�$ (commencing with Section?000)of Division 3 of the Business and Profusions CMe)or $10712
that be u ther
exempt efrom asd the basis fm
the alleged exemption.My violation of
Semon 7031.5 by 4"applicant for a permit subjects thc applicant an a civil penalty of APN Number Occupancy Type
not mom man five hundred dollars($50)). P Y YP
0 1,u owner of the property,Or my employees with wages u thea We mmpmadon,
will do the woh aM the stmcture is not inendeed or aRered Russia(Sa.?Oad,Business
and Profeuioas Core:The ComacerS License law does ret apply Or an comer of Required Inspections
progeny,who WTls or improve theeon,and who doessuch work himulfor through his
own employees.provided that such improvements art not inendW or offered for We.If,
however.the Wilding or improvement is sold within one yeti of completion.the owmr-
Wildcr will have the Wrden of proving that M did ret buil or improve far purpose of
sale.).
KIK1.as owner of the property,am exclusively contracting wire licensed contractors e
uuct the project(Sm.71)44.Business and proportions Cade:)The Conuanor's Li-
cense law does not apply a an owner of pmpeny,w'ho Wilds or improves thereon,and,
who eonnca for such projects with a contracer(s)licensed pursuant in the Contractor's
License law.
01omc rept un�erB ,B&PCfor this on
\.s/4.s vy6saa
WORKERSC NSATION DECLARATION
erehy IMm under penalty of perjury one of the following deehntions:
0]him and will maintain a Certihca s of Consent o self-inure for Worker's Compen.
radon,as provided for by Section 3100 of the labor Code,for the performance of the
..it for which this permit is issued.
0 1 have and will maintain Worker's Compensation Inausanu,as required by Section
3700 of the LaWr Code,for Ne performance of the wart far which this permit is issued.
My Workces Compenation Insunree sterner and Policy number are:
Carries. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=am reed not be completed drte permit is foram,hundreddollars(5100)
Or loss)
1 certify Not in the pean man a of the work for which Nis Mrtnir is issuer,J shall at 1 tr \
employ any'pc many mannc !at cc s �cuothc Works ' pensauon
Laws of Cali10 1 Ove
` ` /. t r 11
NOTICE TO (CANT:If„rdur akjn th Cendicae of Exemption,you should L \- fLl'.
bttome subjres the Worker Compensation provisions or rhe labor Code,you nun s1A_7//
.J�[ foMwith comp Y with such pmvixinm or oris permit Nall W deemed revoked. / /
z O CONSTRUCTION LENDING AGENCY
[-+ I hereby alarm Nat thera iso eommuctinn lending agency for me performance of
me.,it fur which Nis permit is issued(Sec.3W7,Civ.C.)
Ig1 Q Lender's Name
6.
7Z lanOu's Address
CJ Q I certify and 1 have rad this application Aral nate that the above
ws relating u
U coned 1 agree to comply with all city and county nNinancef and sate laws r upon Ito
se
V abom-gcontrucriooend hereby authonP reoises, rives of Niscity to erten upon the
fto abovcmentiunm property for Inspection puryuus
1 (We)agree a save,indemnify and keep harmless the City of Cupertino against
rq incoide;)udgmcnheloading expenor Which may in any war'accrue against said City
t)z in consequence of the grantin of rhinnit. �'/
APjs CANT UND S D'WILL COMP ,VITH ALL NON-PO NT Issued by: Date
SO R BREGULAAnO /
° Re-roofs
S' teas eofA lican on er e
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future Wilding occupant ams or handle hvardon material
as&flood by the Cupertino Municipal Cao.Chapter 9.13,and the Halm and Safety
•.Section ss532(a)?
❑Yu lop All roofs shall be inspected prior to any roofing material being installed.
. XNo
Will the aPPlicam or(urate Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harudous air contaminated as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes b�Nu
1 have read Ne bvaduus maeradsrecuiremend under ChaPer G95 of de Califar.
nulfulm 4SafuYCade,Secdmf23505.2j53S`ed 2553d.l undcmmE thttifthe Wilding
Jas -I]mndY ha J
ms IGx t�s�akry�'mY tupordibilityp pDtifY tic asuPant me
re ree hicyna�sl�arr6ri ds isslsmcofa Reiter, Occuoanc j�
Signature of Applicant Date
U-."&aathori ed a ,.( meq,(—� All roof coverings to be Class"B"or better