10030012 REV �
CITY OF CUPERTINO BUILDING PERMIT r � ._2 (�- ( �;
BUILDING ADDRESS: 10556 LARRY WAY CC NTRACTOR:MiCHAEL MCKtNZIE PERMIT NO: 10030012 '
CC NSTRUCTION
i
OWNER'S NAME: ROBERT&CHRISTfNE VAN HOY 35�5 THE ALAMEDA DATE ISSUED:06/142010 1
VER'S PHONE: 4083133826 SA VTA CLARA,CA 95050 PHONE NO:(408)615-8004 �I
❑ LICENSED CONTRACTOR'S DECLARATION i
BLILDING PERMIT INFO: BLDG� ELECT� PLUMB r i
License Class ►_��.�
MECH � RESIDENTIAL � COMMERCIAL� I
Contractor� Date
I hereby affirm that 1 am liccnscd under the provisions of Chapter 9 JO 3 llESCRIPTION:ADD ATTACHED 20X30 IN-LAW QUARTERS(600SQ) ;
(commencing with Section 7000)of Division 3 of the Business&Professions 10/�6/10-REV#2-WOOD DECK/COMPOSITE 17X17& �T 6ri�' J–�Ji L„�n��' �`�
Code and that my license is in full force and effect. �
1 hereby a1'firm under penxlty of perjury one of the following two dectarations:
I have and will maintain a certificate of consent to self-insure f'or Worker's ,
Compensation,as provided for by Section 3700 of the Labor Code,for[he ,
perforn�ance of the work for which this permit is issued. ;
1 have and will maintain Worker's Compensation Insurance,as provided for by S �t Floor Area:
Section 3700 of the Labor Code,for the performance of the work for which[his 9� Valuation:$90000
permit is issued. '
APr Number:31602026.2NDUNIT Occ4pancy Type:
APPLICANT CERTIFICATION i
1 certify that I have read this application and state that the above information is �
correct. I agree to comply with all city and county ordinances and state laws relating
to building consvuction,and hereby authorize representatives of this city to enter ��ERMIT EXPIRES IF WORK IS NOT STARTED �
upon the above mentioned property for inspection purposes. (We)agree to save ;
indemnify and keep harmless the City of Cupertino against liabilities, 'ud ments, �
� g WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said Ciry in consequence of the �$O DAYS FROM LAST CALLED INSPECTION. '
granting of Ihis permit. Additionally,the applicant unders[ands and will comply '
with all non-point source regulations per the Cupertino Municipal Code,Section '
9 �8 Issu;d bv,r��
_���,—�-_—�_���'l,ate:��-Z�i 7.� i
Signature Date —
i
I
OWNER-BUILDER DECLARATION RE-ROOFS: �
1 hereby a(firm that I am exempt from the Contractor's License Law for one of A��«ofs shall be inspected prior to any roofing material being installed.If a roof is �
the following two reasons:
instal ed without first obtaining an inspection,1 agree to remove all new materials for �
1>as owner of the property,or my employees with wages as their sole compensation, �nspe;tion. ;
i
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicanr_ Date: �
Business&Professions Code) �
1,as owner of the property,am exclusively contracting with licen tractors to
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER �
consUuct the project(Sec.7044,Business&Professions Code). �
i
I hereby a1'tirm under penalty of perjury one of the following three i
declarations: HAZA�TtDOUS MATERIALS DISCLOSURE ;
I have and will maintain a Certificate of Consent to self-insure for Worker's I hav� read the hazardous materials requirements under Chapter 6.95 ot the I
Compensation,as provided for by Section 3700 of the Labor Code,for the Califc rnia Health&Safet}�Code,Sections 25505,25533,and 25534. I will maintain j
performance of the work for which this permit is issued. comp iance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensa[ion►nsurance,as provided for by Safet� Code,Section 25532(a)should I store or handle hazardous material. �
Section 3700 of the Labor Code,for the performance of the work for which this Addit onally,should I use equipment or devices which emit hazardous air i
permit is issued. conta ninants as defined by the Bay Area Air Quality Management District I will i
I certify that in the performance of the work for which this permi[is issued,I shall maint�in compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Healtli&Safety Code,Secti s 25 O5,25533,and 25534. ;
not employ any person in any manner so as to become subject to the Worker's � i
Compensation laws of Califomia. lf,after making this certificate of exemption,1 Ow�=o t 'z a �
I
become subject[o the Worker's Compensation provisions of[he Labor Code,1 must � ate:���� ^l� i
forthwith comply with such provisions or this permit shall be deemed rev ed.
�
COIVSTRUCTI LENDING AGENCY '
APPLICANT CERTIFICATION I herety a�rm that there is a construction lending agency for[he performance of work's i
1 certify that 1 have read this application and state that the above information is for wh ch this permit is issued(Sec.3097,Civ C.)
corcect.1 agree to comply with all city and county ordinances and sta[e laws relating Lende-'s Name I
to building construction,and hereby authorize representatives of this city to enter j
upon the above mentioned property for inspection purposes.(We)agree to save Lende•'s Address '
indemnify and keep harmless the City of Cupertino against liabilities,judgments, I
c� 3nd expenses which may accrue against said City in consequence of the �
g �g of this permit.Additionally, he applicant understands and will comply ARCH►TECT'S DE I ARATION '
9 i;g all non-point source regula[ion per th Cupertino Municipal Code,Section I under>tand my plans shall be used as public records. �
n �
Signature Licens�d Professional �
Date � V I