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04080028 CITY OF COPERTINO7,7 77777777777777777 � , , © �I1�.�I0N BUILDING DIVISION .. PERMIT r. q , $ ,7 ,, . .W,. , , �, BUILDING ADDRESS: - S J MYERS CONSTRUCTION PERMITNO040 S 0 02 8 124c; RT7,117Nq CREEK RTAQ"ER'S NAME: PERMIT LSSUE DATE PHONE:COUNTRYWIDE ROME LOANS 74n Amp7y rolINT QQ A-12 QSANITARY C OL N0. ARCHITECDF.NGINEER; BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u0o LICENSED CONIRACTOR'SD LARATION Job Descrl tion OF Thereby affirm Nat 1 am licennad under p h ns of Chapter 9(commencing p U Msec on7 )of DP,Isrm3ofthe Bu' professions Code.and my license is ; nfull fo tic Adz Liccnx ata Lk.M I TI--LAYOUT/LIGHTS/SUPPLY/UPGRADE ADA RESTRM oak crnDEC CONTRACTOR: SJ MYERS CONSTRUCTION ARCHITECTS DELLA SUBCON: THE DRYWALL GUYS (09/14/04) msand my plana ahNl he uxJ ae public rtcnrds O WyU 3 C� Licensed Profcssionel S< OWNER-BUILDER DECLARATION E 1 hcrehy amore that I am exempt from die Contorts License Law for the O O following moon.(Section](131.5,Busioeu and Nafcuinns Cntle:Any city or county r. which requires a permit to construct,alter,improve,demolish.or repair any structure on prior as its issuance,also requires the applicant for such Permit o rile a signed statement that he is licensed pursuanNothe provisions of the Commas Liccnx Law(Chapter 9 Sq.Ft.Floor Area Valuation IS (commencing with Section 7")of Division Sof the Business and Prefeasiona Code)or — Nat he ie exempt tiurefmm and da basis for W alleged exmpdon.Any violation of Section 7031.5 by any applicant for a permit objects the applicantto a civil penalty Of APN Number Occupancy Type not mom than few hundred dollars(5500). 0 1,u owner ofthe property,mmy employees with wages u their sole compensation, willdotm work,and Ceatructure is not intended oroffemd fmsale(See.7044,11uirksa 316250=0 Raired ns and Pmfesvons Code:The Contractors w e License ladoes not apply to an owner of 9 property who builds or im proves Nercon,and who does such work himself or Ihmugh his own employees,provided Nat such improvements are notinknded oroRered tweak,if, ^ 2�U4 however,she building or improvement is old within can year ofcompledon.The owner- OCT /7 builder will have the burden of proving Nernsat he did not huild or improve for purpose of tease 4 - sak.). ❑1,an owner of the property,.Business exclusively Pretensions with littnxd onntrecmn t. BUIL®I N G when La the project(Sec.to a n,wneoand Pretensions Code:)The Convectors rad cense fat does not apply a an owner of property who builds or improver Centra,mtl who conuacu for such presets with a convSemr(s)licensed pursuant m the Convacrrh L' ase Law. an exempt under See. ,Bd:PCfor this reason or Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of Co following deduatirns: 0 I have and will maintain a Certificate of Consent m self-insure for WorkersCompen. Ionto,as provided for by Section 3700 of the labor Code,for the performance of the work for which Nit permit is issued. 0 1 have and will maintain Workers Compensation Insurance,as required by Section 37M of to Labor Code,for the performance of Ne work for which this permit is issued My Workers Compensation lcamem.carriers Phry aljryvrpsh[aram: a r. Poli —CERTIFICATE OF1NFROMWORKERS' COMPENSATION INSURANCE (This Section need not Ire completed lithe permit isforenc hundreddoilan(51010) less.) I certify that in the perf.On. of. dm work for which Cis permit is issurd,I shall not employanype become subjoctm the Workers Compensation Laws of Calirr PPlicent APPUQANT:I a eking thisConditionof Labor Cod youshould c acomp m the Wrr eons or this previsions of Ne Labor Code,you must .�J z forthwith comply with such provisions or Nin permit shell he deemed revoked. z„O CONSTRUCTION LENDING AGENCY E~ lhcrehy efE.Car Cert is a construction lending agency for Ne performanm of pS> Ne work for which this permit is issued(Sec.3097,Civ,C.) W�Q Lenders Name U z Umbra Address U O 1 certify that I have read this application and state Nal the above information is cmnect,I agree m comply with all city and county ordinances and suite laws mining in �U building construction,and hereby emhorix rtPmsenuitivcs of Nis city to enter upon Nc above-mentioned Property for inspection purposes (We)agree to save,indemnify and keep harmleu Ne City of Chumor r against wfA liabilites.judgmem,costs and expmtses which may in anyway accnm againasaid City U Z in consequence of the granting of this permit. APPLICANT NDERS NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCER A s. P Re-roofs of AftUCon am HAZA OUSMATERIALSDISCLOSURE Type of Roof Will Ne applicant or future building OCCIganutom or handle alamousmakrial defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety c.Section 25532(x)? - All roofs shall be inspected prior to any roofing material-being installed. C]Yen e Wil:the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agreelto remove emit haoardrus air conmminants u defined by the Bay Area Air Quality Management all new materials for inspection. District? ff ` ❑Yes o 1 hove mad dm hmardous materials requirements under Chapeart.95 of Ne Califoo- nice HealthAS Cod e,Sectors 25505,25533 and 25534.I undennnd thn if Ce building does not cum ,haw a knen4 Nat it is my responsibility m hotly Cr occupmt of the require n h armiziceofaCerllriCakaf roe tlo L/ Signature of Applicant Date ncr err auN A sem eta All roof coverings to be Class"B"or better