04100104 (2) CITY OF CUPERTINO
BUILDING DIVISION PRRMIT 4.00NT NFORMATION:°a;
BUILDING ADDRESS: PERMIT N0410010-4
9110 MEIGGS LANE
OWNER'S NAME: PERMIT ISSUE DATE
CHRISTINE SHEPARD 10/14/2004
LONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uON
WU LICENSED CONTRACTOR&, rot moot bar Job Description
up 1 Section
affirm that 1 am I1cee Ba under provisions ops ode. Y fmmmensing p
�W wifoh illioicerund 7000)of Division Sof the Business and ProfcssinnsCodc.and myliccnuis
mrml mrke amd effect TEMP POWER POLE
`O'J K License Class Lim.a -
4'c Dunt Contractor
n~ ARCHITECTS DECLARATION / ��
U1 understand my plans shall he used as public records (, `
o G Licensed Professional 7 e
S OWNER-BUILDER DECLARATION /O ` a
.�<� 1 hereby mnrm that 1 am exempt from the Contractor's License Law ler the
i c O following reason,(Section?0315 .am
,Business and Pntfe. oCode:Any city or County
1,m which requires a parol to construct,alter,improve,demnliah,or repair any....Crum $500
b,Ry poor In its ismance.alw requires the applicant forsuch hermit to file asignkd statement
=zc that he is liccnud pursuant to the provisions of the Commclur's Licosa law(Chap M9 Sq. Ft. Floor Area Valuation
¢l—$ (commencing with Section 70CIB of Division 3 of the Business and Profcssim,Code)or
y`<— that he is exempt Therefrom and the basis for the alleged exemption.Any violomm of
Section 703 IS by any applicant for a mount subjects the applicant to a civil penalty of Occupancy Type
col mora than five hundred dollars(35007.
1,as owner opine property,Lir my employees with wages as their sole compensation,
will do the work,and the suuctum is not intended oroffered for sale(Sec.tOM,Business
and Professions Cade:The Contractor's License law does not apply to an owner of Required Inspections
progeny who builds or improves thereon,and who docssuch work himself or through his
n employee,provided that such improvements arc not intended or offered for sale.If.
however.Ate building or improvement is sold within one year.(completion,the owner.
builder will ban the burden of proving that he did not build or improve for purpose of
valyl.
' T,as owner of the properly,am exclusively contracting with licensed contractors aers
Stmcl the project(Sec.1044,Business and Professions Code:)The Contractor's Li-
cense taw does not apply to an owner or properly who builds or improves duction,and,
COwho im trucks for such projects with a contracior(s)liccnud pursuant the Comracroes
Lummus Law,
❑ 1 am cxcmpl under See. B&P C for Nis mason
o �� .S�l/��nale
WORKER'S COMPE ATIOND CLARA ON
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Cenifieae of Canunt to selr-ieum for Warker'scumpen-
sation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this potion is issued.
0 1 have and will maintain Worker's Compensation Ioommiu e,0 required by Section
3700 ofthe labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy numhcr am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This union Cecil nos heeomplered if the Permit is far one hundrod dollars(SIIX)
r less.)
1 certify Nal in the perbmnanee Of the work for which this permit is Tamed,I shall not
employ any Person in any manner so at to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the tabor Code.you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCrI ON LEN DING AGENCY
F^ "' Ihcmby affirm that there is a eonsinction lending agency or the performance of
Cathe work for which this Permit is issued(Sec.3097,Civ.C.)
UJ Q Lender's Name
=z Under'.Address
U 0 1 canopy that I have read This application and look that she above information is
" F correct 1 agree to comply with all city and county ordinances and suite laws relaxing to
C:)U building construction,and hereby authorierepro.enutives of this city to enter upon the
'hove mentioned property For im pectiun purposes. 1/tis(/,�
F y (We)agree to save,indemnify of this and keep harmless The City Lir Cupertino against O f
to liabilities.judgmenta.costs and expenses which may in any way accrue against said Cly
U z
in Consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
tgnamre or ApplikanvLonlme or /d/ am Re-roofs
IIAZARDOUS MATERIALS DISCLOSURE. Type of Roof
Will the applicant Lir future building Occupant store Or handle hmarduu.material
az C1aWi by the Copcni.o Municipal Code.Chapter 9.11,and the Health and Safety
AMLCmlc,Sccies 15512(a):r All roofs shall be inspected prior to any roofing material being installed.
❑Yc. r]yNu
Will thea hca.t or tum buikdin acct ant use equipment If a roof is installed without first obtaining an inspection, I agree to remove
PP g p qui I or devices which bs
mine,? saircnnominantsatdenncdM1ytheBayArcaAirQualityManagement all new materials for inspection.
Uixrin?
❑YesNu
I have mad the ovardt d materials requirements under Chapter 6.95 of the Califor.
nu Health&Safety Code,Smi urs 155(15.25533 and 15534,I undcrsund thd ifthc Wilding
docs not Mrcmly have a tenant tot it is my nt.ponsibility 1.mNty the aco,com m the
requi w'h st. mel prior to issuance or s Pones or Dec arc
nt � Signature ofApplicant .Date
Owner Lir authorized agent D,I All roof coverings to be Class "B" or better