07020066 CITY OF CUPERTINO
BUILDING DIVISION PERMIT fig! K INFQRMAZI€)N::
PERMIT NO.
BUILDING ADDRESS:
10208 CASS PL STEPHANCI HOMES INC 07020066
PERMIT ISSUE DATE
"rNER'S NAME:
LOIS KERSHNER 4335 EL CAMI
SANITARY NO. CONTROL NO.
PHONE:
(650) 94S,-1281
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i
CC LICENSED CONTRACTOR'S DECLARATION Job Description
W
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z W with Section 70(10)of Division 3 of the Business and Professions code,and my license is 358 ' FAP 1I LY ROOM ADDITION. NO REMODEL OF EXISTING
=y in full force and effeS6
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ZLicense Class L5 Lic•0^�p Date V44F 2 10-1, Contractor
ARCHITECTS DECL.ARATI
i I understand my plans shall be used as public records
)dU
U.1`- Licensed Professional
<
OWNER-BUILDER DECLARATION
aI hereby affirm that 1 am exefnpi from the Contractor's License Law for the
p oyfollowing reason.(Section 7031.5,Business and Professions Code:Any city or county
$Ic which requires a permit to construct,alter,improve,demolish,or repair any structure
o ti prior to its issuance,also requires the applicant for such permit to file a signed statement Ft. Floor Area Valuation
?< that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter 9 >q $76744
H (commencing with Section 7000)of Division 3 of the Business and Professions Cnde)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of N Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3570102.9
�0 Number
not more than five hundred dollars(5500).
0 I,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 sale(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 oroffered for sales 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 conuacting 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 conuactor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
mer 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-insum for Worker's Compcn-
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 Ci
Worker's Compensation Insurance carrier and Policy number arc:
Carrier. s'*f'r`+ Po1-tey No.A'MS 1_(0(3^'H• 0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workcrs'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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
E�—r tom+ 1 hereby affirm that there is a construction lending agency for the performance of
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the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
]z Lender's Address
1 certify that 1 have read this application and state that the above information is
LTO correct.I agree to comply with all city and county ordinances and state laws relating to
J building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
C/i liabilities,'dg rats,costs and expenses which may in any way accrue against said City
U z in consequence Ute granung of this u• Date _ 2
APPLICANT ND RSTAND D WILL COMPLY WITH ALL NON-POINT Issued b)
SOURCE RqH -RDOUS
.
t JJ--- Re-roofs
Sign re of A actor Dam Type of Roof
MATERIALS DISCLOSURE yP
Will applicant or future building occupant store or handle hazardous material
as c y the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety
-de,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes 2
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as deft d by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
I have read the hazardous materials requirements undcrChapter 6.95 of the Califor-
nia Health 3,S cry Cade,Sccuons 25505, d 25534.1 understand that if the building
does not cu tly have a tenant,Ut u my responsibility to notify the occupant of the
require m r use be me nor lu issuance o,a Certificate of Occupancy. Signature•of Applicant Date
3 6Z_43 All roof coverings to be Class"B"or better
net or aur rized agcAe Datc