07030138 CITY OF CUPERTINO
BUILDING DIVISION PERMITINF
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PERMIT NO.
BUILDING ADDRESS:
10026 CRESCENT RD JONATHAN VAN DEN BERG 07030138
PERMIT ISSUE DATE
^rruNER'S NAME:
JONATHAN VAN DEN BERG 03/27/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
i
00 LICENSED CONTRACTOR'S DECLARATION Job Description
v): I hereby affirm that I am licensed under provisions of Chapter 9(commencing
:z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is REVISION-REPLACED TUB W/LARGER CAPACITY TUB-PLAN
t<°• in full force and effect.
On License Class Lie. CHANGE FROM THE ORIG STRUCTURAL FLOOR CHANGE.
E p Date Contractor
ARCHITECTS DECLARATION ORIG PERMIT #06090038 NO NEW PERMIT.
i a< I understand my plans shall be used as public records
)qU
U.y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O 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 r 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 Uccnsc Law(Chapter 9 q
t– (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 0
u 5 F 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 ofNumber Occupancy Type
not more than five hundred dollars(5500). 3261704t"AF�1
❑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 docs 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
saleJ.
as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business 'ons Code:)The Contractor's Li-
cense Law does not apply to an owner of roperty w builds or improves thereon,and,
who contracts f r such projects with a co tractor(s)li sed pursuant to the Contractor's
License taw.
❑I am exemp a der B&P C for this reason
ler Date 3.27-O
K COMPEN DECLARATION
a. I hereby rim under penalty,of peq following declarations:
❑I have and will maintain a Certificate of Consent to se -asurefor Worker's 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 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. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars($100)
or less.)
I certi(v that in a performance of the work C h this permit is issued,1 shall not
employ any pc n y m r so as to box c ct the Workers'Compensation
Laws of Califo a
Applicant
NOTICE P CA :If,after making this Certi tate Exemption,you should
become so t c Worker's Compensation provi' ns of thk Labor Code,you must
O forthwith comply with such provisions or this permit%AG
d med revoked.
Z— CONSTRUCTION LENDING
(�— Ihereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(See.3097,Civ.C.)
CW A
Lender's Name
Z Lender's Address
U 0 I certify that I have read this application and state that the above information is
LL, r correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
C?r (We)agree to save,indemnify and keep harmless the City of Cupertino against
cn liaAconucace
gments,costs and expenses which may in any way accrue against said City
U z in of the granting of this permit. Date �AT DERSTA DS AND WILL C PLY I ALL NON-POINT Issued by:
SONS.
Re-roofsSippliC.UContractor °a" Type of R sof
HAZARDOUS MATERIALS DISCLUSUREWill the applicant or future building occupant storehazardous material
az defined by the Cupertino Municipal Code.Chaplcr 9.1Health and Safety
df Q ionYes 25532(a)? J610 All roofs:;hall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof i:;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants az defined by the Bay Arca Air Quality Management all new m 3terials for inspection.
District?
Q Yes KNu
1 have read the hazardous materials requi mens der Chapter 6.95 of the Califor-
nia He &Safct otic,So:ctians 25505.25533 255 .1 undersund thatif the building
does no u ,sly a a tenant,that it is my nsi lity to notify the occupant of the
rcyuiremc m t be met prior to issu f crtiftcate of Occupancy. Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner ora erircd agent Date