07050274 CITY OF CUPERTINO
t�
BUILDING DIVISION PERMIT � RL � � � *
PERMIT NO.
BUILDING ADDRESS:
10421 SCENIC BLVD TBD - r.10 BE DETERMINED 07050274
PERMIT ISSUE DATE
OWNER'S NAME:
JEFFREY W MYERS 7
SANITARY NO. CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: HOUSE DEMO
BLDG ELECT PLUMB MECH
c p LICENSED CONTRACTOR'S DECLARATIONNEED Job Description
U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z L with Section 7000)of Division 3 of Ute Business and Professions Code.and my license is
r H in full force and effect
j ? License Class Lic•8
3 F O Date Contractor
ARCHITECTS DECLARATION
7 a a I understand my plans shall be used as public records
)WU
U.y Licensed Professional
ON OWNER-BUILDER DECLARATION
C
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z yy prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
's_z that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area
x t- (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sae(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,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
X1.
as owner of the property.am exclusively contracting with licensed contractors to
tract the p Act(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law d no apply an owner of property who builds or improves thereon,and.
who contracts r It p cut ith a contractor(s)licensed pursuant to the contractor's
License Law.
❑I am exem t r B&P C fordlis n
Owner Date
ORKER'S MPENSATION DECLARATION
hidwill
um under Ity of perjury one of the following declarations:
C]I hs maintain a Certificate of Consent to self-insure for Workees Compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers 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 are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or less.)
I certify that in the per rm cc th ork fo tch this t is' d,I shall not
employ any person in me subject t nation
Laws of California.D
Applicant
NOTICE 7AP : after aking this Certificate ofExemption,you should
become sur's Cpcnsation provisions of Ne Labor Code,you mast
Oforthwith cprovisions or this permit shall be deemed revoked.
Z " STRUCf10N LENDING AGENCY
(~- I hereby affirm that there is a construction lending agency for the performance of
pC.� the work for which this permit is issued(Sec.3097,Civ.C.)
AWA
Lender's Name
a z Lender's Address
V C) I certify that I have read this application and state that the above information is
t- correct.I agree to comply with all city and county ordinances and state laws relating to
rJ Ubuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned roperty for inspection purposes.
a (We)agre to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgm nts, sts and expenses which may in any way accrue against said City
U Z in consequence f th rantin of this permit.
APPLICANT N A D AND W OMPLY WITH ALL ON-P INT Issued by: Date
SOURCERE L
Re-roofs
Signatu u ontracto Type of Roof
AR S MATERIALS DISCLOSURE yP
ill a lic t or future building occupant store or handle hazardous materia(
as deft cd the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code, c' n25532(a)? All roofs shall be inspected prior to any roofing material being installed.
es o
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? —/
❑Yes 1iS�t
I have read a rdous m ria quiremens under aptcr 6.95 of the Califor-
nia Hcalth&Sara C , ctions 5 3 and understand that if the bu'ding
docs net current] cnan
is
r onsihility to no' th occupau of
requirements w toiss cc of a Certificate f may. 0 Signature of Applicant Date
(/J All roof coverings to be Class"B"or better
Owner sera h izcd agent Date
J