10010058CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22303 N DE ANZA CIR
CONTRACTOR: JACK MYERS PERMIT NO: 10010058
CONSTRUCTION
C 'BR'S NAME: MARK AAKER & GAIL BROWNELL
27610 NATOMA RD DATE ISSUED: 01/13/2010
LOS ALTOS HILLS, CA 94022 PHONE NO: (408)761-1185
ONVNER'S PHONE: 4087611185
ELECT PLUMB
CONTRACTOR'S DECLARATION
❑ LICENSED C
T INFO: BLDG
BUILDING PERMIT
Class Lic. # 3
MEC g RESIDENTIAL COMMERCIAL
License
Contract Date �l l v
'sion 9
JOB DESCRIPTION: REMODEL 60 SQ FT TO BATHROOM NON-STRUCTURAL
of C a ter
I hereby rm that I am lice ed under the prove p
ng with Section 7 0) of Division 3 of the Business & Professions
(commen
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Valuation: $8000
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 35602026.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
and county ordinances and state laws relating
PERM IT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
costs, and expenses which may accrue against said City in consequence of the
Additionally, the applicant understands and will comply
granting of this permit.
with all non -point source regulations Wr the Cupertino Municipal Code, Section
Date:
Issued by:
9.18.
4�e 3 v
Date
S' Iur
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
❑ OWNER -BUILDER DECLARATION
installed without first obtaining an inspection, I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business &Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
I have read the hazardous materials requirements under Chapter 6.95 of the
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Mde, Chapter a Hea
ial lth &
Comp ensation, as p rovided for by Section 3700 of the Labor Code, for the
d the
compliance with the Cupertino
Safety Code, Section 25532(a) should I stal ore d e ha .12
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Sections 25505, 25533, and 25534.
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 Worker's
of exemption, I
Ow r r aut ut' Date: ori
Compensation laws of California. If, after making this certificate
become subject to the Worker's Compensation provisions of the Labor Code, I must
or this shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions permit
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C.)
I certify that I have read this application and state that the above information is
and state laws relating
Lender's Name
correct. I agree to comply with all city and county ordinances
to building construction, and hereby authorize representatives of this city to enter
Lender's Address
V he above mentioned property for inspection purposes. (We) agree to save
i. and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
.1ify
cost , and expenses which may accrue against said City in consequence of the
of this Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
granting permit.
with all non -point source regulations r the Cupertino Municipal Code, Section
Licensed Professional
9.18.
3 �,
Signature Date _/