07020051 CITY OF CUPERTINO � 1 TG +E'/I2 I }RMETIfN'`
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING LA POLLOCK JEFFREY J AND 07020051
UU j� —` pERMTT ISSUE DATE
OWNER'S NAME: 02/08/2007
POLLOCK JEFFREY J AND BRENDA SANITARY NO. CONTROL NO.
f'rIUNE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
e F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing REMODEL 2 BATHROOMS NON STRUCTURAL
=Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect
�=z License Class ) Lie.a s�78 S WM. H. FRY CONSTRUCTION PAID BL 2/8/07
F-wDale�.r Contra wa-at H rmt CPJ-9, C
,t ARCHr1ECTS DECLARATION
C< I understand my plans shall be used as public records
DWU
U.in Licensed Professional
O< OWNER-BUILDER DECLARATION
Ay-J
< 1 hereby affirm that 1 am exempt from the Contractor's License Law for e
i p O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter.improve,dcmalish,or repair any structure Valuation
u"y prior m its issuance,also requires the applicant for such permit to file a signed statementj Ft.Floor Area
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9F35923003
q $46000
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 5 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Olvcu anC T e
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ` �Number P Y yP
not more than five hundred dollars(5500).
0 1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or imprnves thereon,and who does such work himself or through his
own employers,provided that such improvements are not intended or offered for sale.if,
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. B&P C for this reason
0 I am exempt under Sec.
-,-net Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Consent to self-insure for workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier 4
tuft �2yIP Y �spol�icyNo.: /4o42S31 S�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section Faced not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
2 forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Fy� I hereby affirm that there is a construed lending agency for the performance of
(x> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
az Lender's Address
V ZI certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorise representatives of this city to corer upon the
above-mentioned property for inspection purposes.
W
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
C)Zin consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE RE ULATIONS. ° -
/.��� A Z rs-o"t Re-roof
Signal of Applicant/Con for Dam Type of Roof
HAZARDOUS ATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes id No
Will the applicant or future building occupant use equipment or devices which
If a zoo is installed without first obtaining an inspection,l agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes �Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the Date
requirements which must be met prior to issuance of a Certificate of Occupancy. S ignatu Ce of Applicant
1-�"0 7 All roof coverings to be Class"B"or better
Own r o w�ldC 1`�--horized agent Date