05070111CITY OF CUPERTINO
INF<ORMATIO,N
BUILDING DIVISION PERMIT
CONTRACTOR
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BUILDING ADDRESS:
PERMIT NO. 05070111
10201 YOSHINO PL
ER'S NAME:
PERMIT nut DATE
JENNIFER GEISLER
6
PRONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7W0) of Divlai.n 3 tof the Business and Profcuions Cade.and my license is
infull mmaand client.
264' ADDITION-BEDROOM REMODEL 255'
Drente Clma Lk.x
Dam Lle.#ter
CONVERT BEDRM TO MSTR BATHRM
ARCHITECTS DECLARATION
1 undcraund my plans shall W used as public mcorN
Liaxnsed Professional
OWNER-BUILDER DECLARATION
1 hereby aline that I am exempt from the Commuters License Law for the
following mason (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit t. eonstme4 alto. Improve, demolish, or repair any swmum
prior to its issuance. also reforms the applicant (a, such pcnni, In File. signed sutement
that he is licensed indermt to the pmvisionsof the cantracmr, U.. Law (chapter, 9
Sq. Ft. Floor Area
Valu 165593
(commencing with Smuon 7000) a Division 3 close Businessand Professions Cade) or
that he is exempt therefrom and the basis for the alleged exempsian Any violation of
{ N Number
ane
Occupancy Type
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Section 7031.5 by my applicant ter a permit subjects the applicant as a civil Penalty of
not mom than five hundred dollars (5500).
3 / 03021.00
❑ 1. m owner of the property, m my employes with wage u their salt compemdon,
Required Inspections
will do the work and On structure is notinteMed or offered Intrude (Sac. 7044. Business
and Professions Cade: The Committers License Law don not apply m an owner of
,,.pen, who builds arimprovm Nercon,and who doeasnehworkhimselfor through his
own emPlaYocs, provided our such improwmems ate not intended m.Rered farsak. If.
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b.weaer. Ne Wilding.r improvement is to within... ycarmimpwo n, Neowner.
builder will have the burden m proving that W did not build or improve for Purpose of
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JO
salede
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. [:]I, m owner of tors, properly. am exclusively morward., with licensed cmuannrs m
consumer the Project (Sec. 7014. Bus was and Professors Code) The Contractor's U.
cense law does not apply m an owner of property who Wilds or improves themon, and,
who canuacu for such projew with a... uadui lid pursuant to the Ce undefors
Lmcrmse Law.
❑ramex rept under See .B&PC fm this mason
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cr Dam if
WORKER' OMP ATION DECLARATION
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S 1 hereby a.Mer 1ty of perjury one of the following declarations:
❑ 1 hew and will animain • Certificate of Cmuem m self-insure fm %rdwee.Cmnpm.
ration, of Provided fm by Section 3700 of the labor Code. for the performances of site
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Inaunnm, as toquimd by Section
37M of site labor Cade, for Ne performance of Ne work for which Nis permit is Issued.
'
My Workers Compensation Insurance comer and Policy number am:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Iris acedim acd not W completed if the permit is far one hundrddoRam ($100)
+
or less)
I certify that in the performance m Nc wart for which this Permit is Wood. 1 shall Inst
nP1'my' peram many .!L., as o-0Cc sub 'ecls N Workers' Compmw0on
La ws ofctOn Dam
Applicant q'
NOTICE TO APP A ILS fuer making this CeniRcate of Exemption, you mould
become subjm.an rk
Woers ompcwueprovisionaddue LWr Cade.yaumuu
faMwith comply with such Pravuiam on Nis permit shall he do alo d rewked.
CONSTRUCTION LENDING AGENCY
1 hereby Ne mere I,. consmrc. holding'gency for the perfonnance of
which lid
limLa warts for which this pemtir U issued (Si.l(19T, Co.Civ. C.)
Landers Nam.
Lcndefs Address
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I certify that I have mad this application and sum than the be. information is
correct, ) agree to comply with all city and county ordinances and sum laws relating to
building conswction, and hereby amhtoriM representatives of this city to enter Orion Ne
.b.c-mentioned prepeny for inspection purposes.
(We) acme to cove, an and Levi) harmless City of Copcnits against
estimated w
ju costa and expense which may N any way acrnm against said City
iliabilities. c,lumic. of toof this permit
m consequence of DERST
N
APPLICANT UNDERSTANDS NO WILL COMPLY WITH ALL NON-POIM
Issued by: Date
RCE REGU ONS.
Re-roofs
Si mof Appli uContnnm te
AZARDOUS MATERIALS DISROSURE
Type of Roof
WillNc app' t of forum Wilding aivpantuore or W. harallous materiil
as de rad by the Cupertino Municipal Code. Chapter 9.11. aM the Health and Safety
. section 255324)?
❑Tse Q No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicator or for.. Wilding mcupoor and equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
mail hwommns air crnuminana m dcfnd by Ne Bay Am. Air Quality Mmajimim,
all new materials for inspection.
cosmic'?
❑yea lyclry
1 have mad Ne hmaAnusmaterials requiremens underCTapmr6.95 of NeCalifor-
nia H.IN& Sef IYCade, Scoums15505.25533 and 25534.1 undersand NatirN. building
docs not currently Mw tenant
.that na. Nat it a my mapemm ibiliry notify the uvcupont or the
m 'reaenuwhichm rWmct Prior issuanccifaccmm�camafol mry.t
Q 6.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
own. ar..Narnd rat D,m .L