01080016 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10471 STERLING BLVD. CHEVAL CONSTRUCTION INC 01080016
OWNER'S NAME: APPLICATION SUB DATE
TED ROBERTS 996 DARK ST 08/03/2001
PHONE: (210) 521-7421 SANITARY NO. CONTROL NO.
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g 0 Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
0_ BLDG ELECT PLUMB MECH
aia L_J
hN Job Description
Z' LICENSED CONTRACTOR'S DECLARATION
Z_ 1 hereby affirm Nm 1 am licensed sines provisions Professions
ode9lcmmmmense
, with Scaion)BA)m(DivisimnJmftheBusinessandPmfcssiunsCodgafmylicen TEMP POWER.
sem y= is,an full force an ea. 36 /
z License s Lic.p
i Dae - - Contractor
r
a LLO m ` u ARCHIT[CT'g DECLARATION
1 understand my plans wall be used a.,public moods
se M
a c Licensed Professional
°W'6 se OWNER-BUILDER DECLARATION
u�='a I hereby uffmm On,1 am exempt from the Commumr's License Law fur the
t? fnllow'mg reason.(Section 7031 5,Business and Professions Code:Any city or county 6 Q
zwhich requires a permit to construct,alreq improve demolish,or repair any structure Y
w ..prior to its-sotance.alsonuIcims dicapplicantI Ipemu tfI g mm
signed
c. Nathe licapiedpm l,ionic F isiu f the Contractors I tt 1 '(Clupmr9
X , . , 1 - f Valuation
(c mono e .lh S10()) fDiv.bnl.1 the Bsnes and Professions Code) 3,7, 2bV3q0" •
-,! L-
or Nat he is exempt Ncrefrmn and the basis for the alleged exemption.Any violation
-nf Section 7031.5 by any appluum for a permit subjects the applicant m a civil al
•mr nm comm Nan.r a hundred dinars(S500). 103 APN yV Lpker Occupancy Type
01,asownerof Ne property.mr my employees with wages as their sole compensation. -
will do the wok,and she swcturc 1,oWiaended or offered for sale(Sol.7W
Business
-
Business'and Professions Code:The Commaur's License Law does not apply to an Required Inspections,
rtit
owner of propeny Who builds or Improves:hereon,and who does such work himself
of through his own employees.provided Na such vermhu menu o i not:mended or
'-
"oRcrWfar sold If.hmvevcr,Nc building ns sold tvidtin one-ear of -- -- �-- � ---- --- - - --_- ----- -- -- .
ger tmen of pro y o 1
improve for the ownerbolo.).will have the When of proving that he did not Wild or
improve f p rpo of solo.).
_01 of the propeny.am exclusively contracting with licensed ctractors to
construct the project(Sec 7614 Business d Professions Cob:)no Cmatraltorts, „
License Low does not apply to an owner of propeny who Wilds or improves thereon,O
and-who.contracts for such proms w N 0 commissions)ficenthred pursuant to the. _. .. . ._ _ . . .._
Cut t Licamsc Law. J-
01 a n exempt under see. .B&.P C for Nis reason .,1P
.. Owner ,n Data .. .�
WORKER'S COMPENSATION DECLARATION
I hcrcby affirm umler penalty of perjury,dac of the following ticdarations
❑ I have and will maintain a Cenificom of Cohost it soli-insure for Worker's
Compensation, it, provided for by Section 39W of he Labor Cods. for the
performance o!the work for which Nis parmit is issued.
01 have and will'muinmin Worker's Conipciisalod Insurance,as required by Section
'TIBO Of he Lnhmr Code,far the'plrformance Of the work for which this permit Is
issued.My Worker'.:Coinpensation Insurance carrier and Policy number arc:
Gyres 57..A1- .woo 'Policy No,12mg`o!'oZ3�43 �-
cF,R"fIFICATION OF EXEMMON'FROM WORKERS�sr - •' -- ` '
'Co NIPENSAT10N INSURANCE - + .._... . . ......._... _ _ ___ ...._..,._.-
iThis uciian need not bei complied if the permit is for one hundred dollars `
IS 100)or loss.)
I nifychat nthe performancefNe work for whichN parrot is issued ) - - :,knit•, rt _ _ _. .... ._
, not employ city person 1n any mamma sat us td bs,omc subjm to the workers'
Compensation Law,mf Caifornia,Date ' "
Applicant.
NOTICE TO APPLICANT;Ill after making this CeniGcam of Exemption,Y.should t -
i
Q z
' become subject t the Worker compensation provisions of
lt the or
Code,Yo
u mustford pwnh N pe hall Deemed revoked.
EQ ry . _- —Wre _ . . __ ... .. . . ...
W ..
'`'1 „
_ ' uCONSTRUCTION LENDING AGENCY
7 1 bxrebv Off"that there is a ednswnion lending agency for to perfommnce t '
^ o!NLwmk for which this pctmit is issued Sec.309].Civ,C.I'
0W Q finder's Name' ' - - - -- - -- --- -
. ..•-). Z' Lender's Andress;', - „
VI certify that 1 have read this application and sure that the above inform pion is
(s..F. c s l agree to comply with all city d county ordinances and scam laws hadating
Q f)
to bIdngcon.uu t n dhereby authorize rep000ntatives, fN city t rat ion
r� the advise memoned pirpe it,1or im"etima' p po e _
Fr'0+ (Welber n fy dkgh I .NC'lyfCptno'gina
Vi liabilities,judgments.costsJ expenses which may,in any way accrue against said c /
_[) z City to con cquence of the granting of this verion
^
'APPLICANT UNDERSTANDS AND WILL COMPLY N'ITHALL NON POINT - Issued b Date
SOURCE REGULATIONS.. i . . Y'
Signature of Applaurn/Comiaaor•' "„i`I,.. .Dine': Re-roofs
s defined •HAZARDOUS MATERIALS DISCLOSURE
wli'me,;pprca6tmrmwreWuaina�capantatuemrWnmtna,5tdmas�,tatetiar Type of Roof
by the Cupertino Municipal Cade,Chapter 9.12,and to Health and Safety ,
CoJc 5❑cYc n 25512( 1 , ClN t.i } ( .s.
' • � � ` �• ' ` �” ' ' .. . All roofs.shall.be.inspecled.prior[o any.roofing material being installed..- .....
.,win mea licant ser future buildin occupant star device,which �'
pv dby the B a Tres If a roof is installed first obtaining an inspection;Pabree to 'remove
emit hazallous air conmminams as defined by Nc Bar Area Air Quality Management
'District all new materials for inspection. Applicant understands and will comply with
t°Y4' ON.,. all non-point source regulations.
I have reanine hamNoui maenads rcgblrcmenfa undcu Chap er ti 95 of the
California Health&Safety Coda Sections 25505.255]3 and 25534.1 understand Nat
it NeWilding docs notcurrently have a m int.that n is my iesponsibility to notify the
accupam of the ou,n oss nu which must Its,unit prior to issuance of a Certificate of
.. Occupancy., -'
.. '--- - • ' � � Signature of Applicant„ - . - . , - _ .Date_ _
- .ownermranmmdttdagent' " Data All roof coverings to be Class "B" or better -
OFFICE