04060160 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ATI
BUILDING ADDRESS: PERMff NC0 4 0 6 0 16 0
10560 E ESTATES
OWNER'S NAME: PERMIT I SUE DATE
JERRY STEVENS 06/18/2004
VE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+O, LICENSED CONTRACTOR'S DECLARATION
m❑ I beroby affirm that I am limned under provisions of Chapter 9(commencing Job Description
iW with Section 7")of Division Sof the Busiceax and Professfom Code.aw my license is
"<oH mmnmmeawerRa ADD 137 SQ. FT. (LIVING ROOM)
Liccnx Class Lk." ,
t r o Date Contractor
ARCHITECTS DECLARATION
5a is 1 uwersuind my plans shall he uud as public records
J ou
N Cleaned Professional
5 OWNER-BUIIDER DECLARATION
I hereby affirm that I am exempt from the ContmctWs License Law for the
o o following mason.(Section 703 1.5,Business and Profcasiuns Cade:Any city or county
K m�+ which mquifes a permit m conmuct,alter,improve,dermluh,or repair any structure $20000
prior m its issuance.also toqumis she applicant for such Permit to Glc a signed statement
< that he is licensed pursuant to the previsions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
oeFo (commencing with Section 7")of Division 3 of the Business and Professions Code)or
i R S that he is exempt thmcfrom and de basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of Df Occupancy Type
not mom Nan five hundred dela.(S500).
❑1,as owner of the property,in my employees with wages as their solo compensation,
will do the work. oil theswaure is no,intended or nffa.d for salc(Sec.704<,Bnsinw Required Inspections
and Professions Code:The CRntraaors License Law does not apply to an owner of q P
Own employ b.pmvirimpoves thare0nand who docasuch dome lnumdc himulfo,throughhis p /� �I
Own crty who bis provided Nat such improvements art not intended or offered for ula.lf. �puVIry14`//..\~\�\1IIpIS
howcvcq the building or impmmmem is sold within ane yes of mmplcuon,the owncr-
ED
builder will have the burden of proving Nat he did not Wild or improve for purpose of
til ).
1.as owner of the property,am exclusively contracting with licensed commemor m SEP 0 8 2004
convect the project(Sec.7064,Business and Professions Codep The Contractor's Lt.
cones Law docs not apply to an owner of popery who Wilds or impmma themun,and.
who Lacui le,such
rojccu with aconuacmf(H licensed pursuensmlM Convavtors ����®B� �p
Licence taw.
❑lam exempt oder c. B A P C for this maven
o 'I'1. D '1B"
WORT F!1'S COMPENSATION OECLA\f+D7
I hereby affirm under pcnahy of perjury aro of the following declarations:
ham and will maintain aCenifia¢of Consent in self-imure for WorYeri Compcn-
tion,as provided for by Section 3700 of the Labor Code.for Ne Performance of the
work for which this permit is issued.
1 have and will maintain Worker"Compcmuion Insurance,u required by Section
37W of the Labor Code,for the performance of the work for which this Permit is issued
My Wmk,ea Compensation Insursna carie,and Poli,number art:
Carriee Poli,No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Trois section need not be completed if the Permit is foronc hundred dollar(1I00)
or I..)
1 certify Drat in the perfonumc,of the work for which this Permit is issued.I shell not
employ any person in any manner w as to become subject to the Worker'Compmuation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compeaation provisions of tbe Labor Code.you moa
,JO forthwith comply with such provisions of this Permit shall W deemed invoked.
Z CONSTRUCTION LENDING AGENCY
E-. 1 hereby affirm that them is a construction lending agency for the Performance of
Q', > the work for which Zhu permit is issued(Sec.3097.Ci,C.)
U Q Under"Name
G Lender's Address
U 0 1 certify 0.11 have mad this application and suite that thc aWm information is
w H correct 1 agree to comply with all city and county ordinances and mute laws misting to
0 U building conswetinn,and hereby audiorm mpresenutimf of this city m enter upon the
} LS7 &how mentioncd properly for impeetion purposov
(We)agree to um,indemnify and keep harmless the City of Cummins against
F' I, liabilities,judgments.costs and expenses which may in any way accrue against said City
U z in cOma tonce for g nun"of this Permit.
^ APPLICANT NDER TANDS AND WILL COMPLY WITH ALL NON-PO NT Issued by: Date
SOURCE REG LAT10 S. /_,16r 4
(V Re-roofs
gnamrc IicaHVAZAnRDOUS MATERIALS DISCLOSUREtor ate Type of Roof
Will the applicant or future building occupantstom or handle hvallous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heald and Safety
Code. 0y.25532(.)'. -t All roofs shall be inspected prior to any roofing material being installed.
Yes �LNo
Will the applicant or future building occupant use equipment or devils which If a roof is installed without firs[obtaining an inspection,I agree to remove
harafdoor air contaminants u defined by Ne Bay Ama Air Quality Management all new materials for inspection.
suim9
❑Yes <No
1 have mad the havardnus materials requirements under Cholla b.95 of the Cslifof-
ofsHcalth&SafetyCade, c=255f15,25533and25534.1uwcrsun iflM Wilding
dna not eunem hoe a nano Nal it ii my fespon"ihility m notify the mcupant nl the
mgaimmcroswh Ill mat mctpriormiuumceofaCewrie orae Ney' Signature of Applicant Date
mer mf ammpdacd a4lent
r D All roof coverings to be Class "B" or better
t