05060096 (3) CITY OF CUPERTINO �* a
BUILDING DIVISION PERMIT = CONTRACTOR INFORMATION .:
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BUILDING ADDRESS: JACK MYERS CONSTRUCTION PERMITNO05060096
11411 BUBB RD
ERSNAME PERMIT ISSUE DATE
TAHSEEN ADEEB 1965 COLLEEN DR. Q6Z15/2005
ONE: SANITARY NO. CONTROL NO.
(408) 761-1185
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CHITECT/ENGINEER: BUILDING PERMIT INFO
BLOG ELECT PLUMB MECH
LICENSEDCONTRACIOR'SDECLARATION BvG9I hereby affirm Nal l am licensed under provisions of Chapter 9(commencinglob DescnpnonP�'� �h Section7")ofDivision 3 Olga,Business and Professions Cook.and my license ismaull forte and effect. REMODEL MS BATH
ense Class Lie.p m,.f Date Coo we yl"f 13' ARCHITECPS DECLARATION
�i < 1 understand my plans shall W used as public records
J on U (((fff��� p� rr}T d non
H Licensed Professional
n S OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt form We Contractors License Law for the
zoo following mason.(Section 7031.5,Business and Profcesimu Code:Any city or county
K m gy which mquims a pemli,t0 Construct.alMf.Improve,demolish,nr.pair any amitti m
poor in its issuance,also requires the applicant for such Permit o file a signed statement
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that he is licensed pursuant to We provisions of We Comracmri License Law(Chapter 9 Sq.FI. Floor Area Valuation
xFo (commencing with Section 7")of Division 3 of We Business and Professions Code)or
y War he Is exempt W,.from and We basis for We alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects We applicant to a civil Penally Of erO0 Occupancy Type
not mthan an 6wbandied dollars(5500). P Y YP
CI 1,as owner of the property,a my cmployeu with wages as their sole compensation,
will do We work,and We swaure is not intended or offered for sale(Sec.7044,Business
and Profusions Code:The Contractors License Law docs not apply to an owner of Required Inspections
Property
who buildsor improves thereon,and who doess rch workhimulf or Borough his
own employee,pmvitletl Wal such improvements are not intended oroRered formic.If,
however,me building or improvement is sold within one year of completion,We owner-
builder will have We burden or proving War he did not build or improve for purpose of
salt.).
❑1.as owner Of me property,am exclusively contracting with licensed contractors to
construct the pmject(Sec.7060,Business and Professions Cade:)The Contractor's Li
cease Law does not apply to an owner of propeny who builds or improves Wcreon,and
who contracts for such projects with a conmaor(s)licensed pursuant In the Convectors
License Law. -
❑l am`e'.�emlyf under Sec. .B&P C for this.azon
r vim- I t Date I�
WORKEWYCOMPrNSATION DECLARATION
1 hereby affirm under penalty of perjury one of We fallowing declarations:
I have and will maintain a C,nifiCam of Comic.,to self-foam.for Works]COmpem
radon,as Provided for by Section 37W of We labor Code.for me perfmanance of We
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,az required by Section
37W of me Labor Code,for We pmformance ofthe work for which this permit is issued.
My Workers Compensation Insurance Cartier and Policy number a.:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W comincted if rhe permil is throne hundred dollars(SIM)
or lc u)
1 certify War in We Performance of the work for which this permit is issued.I shall not
employ any person in any mourner x o c m su ecuO the Workers Compensation
Laws of Ca,u mia.Da
Applicant � I'(�Z
NOTICE TO APPLICANT:If,after making this Ccrtifica.O Ex,mprion.you should
become subject to the Worker's Compensation provisions of We Labor Code,you must
.,z foMwi 0 comply wife such provisions or this From it shall be deemed mocked.
z O
PCONSTRUCnON LENDING AGENCY
thereby affirm Wag Were is a construction lending agency for We Performance of
04> me work for which this p,rmil is issued(Sce.3097,Civ.C.)
WQ Lender's Name '
IL Lender's Address
az
U Q I certify Wal 1 have read this application and state that me above information is
W F^ cmrect.I agree to comply with all city and county ordinances and sure laws muting m
17 C.7 building construction.and hereby aummire representative of this City to enter upon We .
}' W above-memioncd property for inspection proposes.
F gy (We)agree to save,indemnify and kap hamadcas We City of Cupertino egainrt
h liabilitie,judgments,costs and expense which may in any way accrue regains said City
V "z in consequence of We granting of this Permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
io
E REGULATI fj }
L✓ f I1�D� Re-roofs
e of Applicants onfeactor D te
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill We applicant or future building Occupant store or handle hamnlous material
d by We Cupertino Municipal Code.Chapter 9.12,and We Health and Safety
ams zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes �Noise We a scant or future buildin acre ant use e If a roof is installed without first obtaining an inspection,I a ree to remove
OP B P aAir uordeviceswhich gartleus air conmminants as defnod by We Bay Arca Air Quality Management aII ROW malerlal$ for m$peCllOn.
�[sYes WNo
1 have mad the haaardousma.oals reyuirements under Chapter 695 of We Cslifor
nia HcaIW&Safcty Cook,Sa OM 23505,25533 and 25536.1 undcrsmnd Wazif the building
Jeer not Currently hate,a tenon, at 0 is my responsibility m nouly IM acupent of me
rats mhmusbcmct 'ro sm cfaC,mretoaf000apmcy. SignatoreofApplicant Date
L � IS
Owner or authorce agem— Date All roof coverings to be Class"B" or better