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CITY OF CUPERTINO'+ea€..�,a�3-�,A'?a
BUILDING DIVISION PERMIT
*.�COiN�, RACTOR iNV�DRMA'CIfJN $.
BUILDINGADDRFSS:
914-71 NZAT A17
MARILYN SCHERMERHORN
PERMIrNo04060210
OWNER'S NAME:
PERMIT MUM DATE
Wl E;
SANITARY gNT110L NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
1 ecteby affirm that I am licensed under pmvisimu of Chafer 9 (commencing
p
with Section 7") of Division 3 of tho Business and Professions Code.and my license is
If BsB forceand efmct'
PATIO COVER
License Claes Lic.0
"
Dam Cunnmler
ARCHITECTS DECLARATION
1 understand my plans shall Ice used u public records
Licensed Prfemanal
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from dm Contractor's License UW for the
following reason. (Section 7031.5, Business and Professions Codc: Any city or county
which rcqu,ms • permit la emuctrect, alter. Mprve, drom1uh, or rcP it any mmcmm
onn
prior to its issuance. also requires done applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
thus he is liccnsed pursuant to the provisions of the Connector's License law(Chapler 9
(commencing wish Section 7") of Division 3 of she Busmess.nd Porro amn. Code) or
that he is exempt therefrom and the basis for the alleged exemption. My violation of
3 OXIX�b@r0 0 Occupancy Type
Semlan 7031.5 by any applicant for a puma subjecu the applicant to a civil Penally of
nm mom Nan five hundred dollen (Sr10).
v
❑ 1, u ownu of she pmpeny, w my employees with wage u Iheir mk eempenuslon,As
will do the work and Nuwcwrt is notimmuded oraffemA forsale (See. 7044, Business
RC 1 s
And Pmfeulow Code: The Conu ecei License Law does not apply la an ..of
property whobulldaor impmvusherean,and oessuchwwk himselfer his
ements rcne for W
for sale,.
shaymch,mpmold
�®
howcrumever. the buildingwithinyaar.ccorofferedetsm,
uip ing or within ore Weld or completion. the owe of
however. the ave use u i enm pelvic,
bulldu wW love tion burden of pmving Nal he did not build aro Improve for purpose of
I, ns ash of , exclusively convecting with licensed contractors
01.
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caoilNel NC pmjem (Bte.7Qi•f, Business and PmfCaa,One Cade:) T)Ie f.'annKbYf V�
O project Sec.7 , B
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does that apply to an owner of pmpenY who builds w improves Hereon. sed,
CIE. unuamm Ne ConvseloYs
W convects fm sue with r( )I
L nse law.
veld
eaten oder , B k P C far His recon
444 ��55s
dM U�
0 COMPENSATION ECLATiffiGM'
I h affirm under penalty of perjury one of the following declarations:
have and will maintain a CenVnmm of Cament m self-inum fm Worker's C=Mn-
mean, u pmvlded for by Section 37M of He labor Code. for He performance of He
work for which His permit is issued.
❑ 1 have and will maintain Wark es Compensation Inmuanm. as mlu,red by Section
3700 of the labor Code, for the performance of the work for which His permit is issued.
My Worker's Campeesation Insurance caniu and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF E%EMMON FROM WORKERS'
COMPENSATION INSURANCE
MOO motion need Am bo completed ,f tM Permit is roronc hundred dollars ($lip)
of last.)
Hal H He perf once o work for with th" penton m naucd, [.hall not
,
nypc n' an nor mWcomc aubj He rkenCompewadanCatlin
41o'y,a,
m
PP A ': L fter reakmg Nis Ccni ¢cam o Excm uon, You shdl"reject
c Worker's Compensation provisions of Oc labor Code, you mum
(mthw,H camp ith such provisions or this manitsill W Account rcv.lmd.
CONSPRU17HON LENDING AGENCY
I hereby aRnm that Here Is a coruwnHn lending agcocy for the performmca of
the work for which this permit is issued (See 309T. Civ. C.)
Undoes Name
Lender's Add.
I cenify that I have fund His application and sum that she ahem information I.
con.. I agree to comply with all city and county ordinances nd suis laws relating or
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Wilding cowwction, and hereby.mhorine representatives or this city in emu upon the
above-memlOMd properly for inspection purpOYs.
(We) agree to... indemnify and hop hVloless the City at Cupertino against
liabikies. judgments. cams and expenses which may In any way accmc against said City
e or on
nPPLICANTUNDERS1n6 of Nb D WILL CO LY ITH ALL NON -POINT
Issued by: Date `
S REQU 0
--7—
Re -roofs
�Da
Ignurrco App1. on for Dem
HAZARDOUS MATERIALS DISCLOSU
Type of Roof
Will He IIcant aro future Wilding occupant uort whsMleheuNow material
u dcOned by Coconino Municipal Code. Chapmr 9.1]. and He Health and Sarmy
code.0 Yes Bp an:ssax(a)7 sss111''' -
All roofs shall be inspected prior to any roofing material being installed.
..
If a roof is installed without first obtaining an inspection, I agree to remove
Will He applicant of ('or`um building occupant useequipment or devices which
M.A.. air contaminants u turned by the Bay Arc. Air Quality Management
all new materials for inspection. '
sn,n7
❑Yea TRfNu
I have mad He hazardous materials requirements under Chapter 6.93 of the Califon
A"'AIH85afclyCode, Scctions25503, 25537 set 2537d.l untcnwd.Holif Ho Wilding
d mast currcntiy baro thm it is my m naib.l.ry m notify He wcupant of she
iremona�w mus me 'ares lases c fat Nficateoroccopancy
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner rf arab .ant Dae)
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CITE' OF CUPERTINO
BUILDING DIVISION PERI_
G�11�TRA�TCIR INFORMt. ON::.
BUILDING ADDRESS:
MARILYN S CHERMERHORN
PERMIT NO
04060210
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY O. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
PATIO COVER
License Class Lic. p
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the pmvisions of the Contractor's Licensc Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 g�j�g-��r0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
,
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
- who contracts for sue rojee with a conlraetor(s) licensed pursuant to the Contractor's
L' ense Law.
'rider
exem . B & P C for this reason
Date r41,111* 0,60!111 d1171—
O S •R'COMPENSA ION ECLATZZMQM'
I her y affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to scif-insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not he completed if the permit is (oronc hundred dollars ($1011)
or less.)
ertify that in the perft ante of, work for whichth" permit is issued, 1 shall not
e. loy any pcgon' an ner 5 to become subje • a the W rkers' Compensation
La f Californ' . to _ `
I APP A : If, aflcr making this Ccnificatc of Exemption, you shc_i_ulldd,
become subject c Worker's Compensation provisions of the Labor Code, you must
forthwith comp ith such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
/
NDS)AND WILL CO LY WITH ALL NO--Ny-POINT
Issued by: Date
SPPLICANT,UNDEROST
Re -roofs
ignawrc o Applic antra for Date
HAZARDOUS MATERIALS DISCLOSU
Type of Roof
W1 IIthelicant or future building occupant store or handle hazardous material
as dcfincd by th Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
11 Yes Op ...ccc.../// No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes 7No
1 havc read the hazardous materials requirements under Chapter 6.95 of the Califor-
n Heahh&Safely Code, Sections 25505, 25533 and 25534.1understand.thatifthe building
d s not currently ha vc that it is my re onsihilily to nosily the occupant of the
r irement-s w h must met' 'or to issuan c f a cenificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or auth a cnt �_ Date