03100137CITY of CUPERTINo
BUILDING DIVISION PERMIT
�XQNTRAOTQR INFORMATIONS
BUILDING ADDRESS:
BASIC CONTRUCTION SERVICES
PERMIT"°'03100137
ERS NAME:
15197 DICKENS AVE
PERMITISSUEDATE
BR MM STEVE AND KRIS
9nn-A
NE:
(408) 3690257
SANITABYNO. CONTROLNO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MP.CH
0 0
LICENSEDmthatICONnRd ION
Job Description
ofs Y (commencing
underSDEdons Of
1 hereby affirm that 1 am undo provi¢i
p
es
with Se�ctio� 7akB of Diviximn 3 of NC Businet..n0 Profc"ium CnJe, antl my license is
fah Ba C.de
"'Sk
Li�cnlx:n int X13\7�
REVISIONS ON SCOPE OF WORKS
Lm'�
Data Contractor
NO NEW PERMIT ISSUED/ORIG. 403080125
// ARCHITECTS D A ION
V(/lstsdRsyand my laria.h.1libcxd"pu menthe
ii�V C : _ _
Licensed Pocssionel
OWNER -BUILDER RATION
1 hcrchy from thatI am escron from the Contractor's License Law for the
following mama (Secuon 703 1.5, Business and Profcsaions Code: Any city or county
which requires a permit m construct, alter, improve, demolish, or repair any strucmm
prior m its issuance, also requires the applicant for such Permit o rile a signed statement
that he is licensed pursuantlo the provisions of the Contractor's License U. (Charter 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Section 7W0) of Division 3 of the Businc¢s and Professinm Crede) or
Nal he Is exempt therefrom and the basis for she alleged exemp0on. Any violation of
39t9i92i0�iler00
OCCU
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than Eve handled do]),. S500).
❑ I, m owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offend or sale IS". 7044. Business
and Professions Code: The Con escmrs License law does not apply to an owner of
q p
propcny who builds or improves thereon, and who does such work himself or through his
own cmployecs, provided Net such Improvements ...I intended.,.(fend for sale. If.
however, the building or improvement amid within one year o(compleuon, the owner.
builder will have the burden of proving Na he did not Wild or improve for purpose of
sale.),
❑ h as owner of the progeny, am exclusively contracting with licensed contractors m
convect Ne project (Sec. 7044, Business and Professions Code:) The Contractor's Lt.
a�
ofpropertywho sed rs orpars impro the thrown. and
come Low does amapply toan with
whocontractsLa for which projects with a contractor(s) licensed pursuant to the Convenor's
License IJW.
\
❑ l sm exempt under See. ,Bd:PCfor this moon
\ v
Data
WORKER'S COMPENSATION DECLARATION
I herby 4MM under penalty of perjury one of the following declarations:
I ban and will maintain a Ceniricam of Consent to self -insure for Workcfa Comfort.
"don, as provided for by Section 37W of the Larval Code, for the performance of the
work for which Nis permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as acquired by Section
3700 of the labor Code, for the performance of the work for which this permit Is issued.
m
My Workc ¢Com sationl sunnce carrier and Policy m�bc�ran�:�
s �..��
C '<r. v , +t J/ PolicyNo,:1rV; �.1 R n _
CERTIFICATE OF E1lFMPDON FROM WORKERS'
COMPENSATION INSURANCE
OTU actions wed not be completed tithe panel, is Throw hundred dollars (SIM)
less.)
1 certify that in the perfsmance of the work for which this Permit Is issued, I shall not
employ any poen in any manner so as to become subject to the Workers' Compensadon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making thus Candlish, of Exemption, you should
become subject to the Workei a Compem ndim provisions of the label Code, you nun
forthwith comply with such provisions or this Permit shall be deemed revoked,
CONSTRUCTION LENDING AG ENCY
I hereby affirm Nat then is a convection lending agency for the Nr(orm race of
Ne work for which this permit is issued (Sec. 301 Civ. C.)
Lender's Name
Lender's Addm"
1 cenify that I have read this application end mo, had be above information is
'
correct. I ei me to comply with all city and county ordinances and sum laws misting to
building convection, and hereby authorine milmuntatives of this city 10 enter upon the
above-mentioned properly for impaction purposes.
(We) agree to save, indemnify and trey harmless the City of Cupertino against
liabll ices, judsmenta, costs and expenses which may in any way accrue against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
5 URCE REGULATI
Re -roofs
Type of Roof
Data
S' eof ApplicanJCr i<bing
HAZARRIALS DISCLOSURE
Will the applicant or occupant store at handle hevutluus material
as defined by the Cupertinoe. Chapter 9.12, mJ the Health and Safety
e. Semon 25s3z(,)7All
roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or cupanl use equipment orJevices which
it hvardeus air conmmimnts as def by the Bay Arta Ail Quality Management
all new materials for Inspection.
e"
❑ Yes
Ihawmad Nehms us unials requirements under Chapter 6.95 of the Califon
nia Health& Safmy Code; onion 505,25533 and 25534. I undcmmnd that ifthe building
docs not currently have a mnank that it u my responsibility to noufy the aceupanI of the
n uimmnhawhfchm t entprimmissuanceofaCcnific ora arty.
Jignature of Applicant Date
.
All roof coverings to be Class "B” or better ,
or authornnd agent
Letter ❑„e