07100007 CITY OF CUPERTINO
: : -
BUILDING DIVISION pERMIT �fiI�T�A.�TflR:I��C��A���flN _
BUfLDING ADDRESS: PERMIT NO.
915 FERNGROVE DR SCENIC SCAPES, INC 07100007 .
OWNER'S NAME: PERMTT LSSUE DATE
BOB & MARY KIRBY 2975 E.�TON AVE 10 01 2 07
NE � SANITARY NO. CONTROL NO.
(650) �95-8800
ARCHI'IECT/ENGINEER: BUILDING PERMIT INFO
HLDG ELECT PLUMB MECH
� o p LICENSED CONTRACTOR'S DECLARATION � � O �
j V� [ hcccby aftirm Wat t am licenscd uadcr provisions oc Chap�cr 9(commcncing JOb DeSCilptlOfl
: z� a wiih Scction 7000) of Division 3 a(thc Busincss and ProCcssions Code and my liccnsc is FENC E 1 ZE PLAC EMENT
,� y in full forec and cffect
�� Z Licensc Ciazs G L 7 Lic. �_- IQ I�SS�Le
:�, p Datc d.�- 1� 2,o.�T Conuaciur 3[ a.�.Z 5 c,.� t
� � ARCHITECI'S DECLARATION
�� U I undcrs�and my plans shall Ix used as puhlic recorJs
,a
� p y L�ccnscd Pn�fcss�onal
� � � OWNER-BUILDER DECLARATION
j a g I hcrcby al'firm �hat 1 am excmpt Crom ihc Coniractars Liccnsc Law for thc
. p O following rcason. (Scction 7031.5, Busincss and Profcssions Calc: Any city ar county
�,°, �i which requiccs a permit to construc4 altcr, improvc, dcmolish, or mpair any swcwre
° Z} pnor � iLS issuancc, also rcquires �hc applicant for such permit to filc a signcd statemcnt
:_ � ihai hc is liccnscd pursuant to thc provisions of �hc Contractur's Liccnse Law (Chaptcr9 Sq. Ft. Floor Area Valuation
u f- �(commencing wi�h Scction 7000) of Division 3 of thc Busincss and Profcssions Cadc) ur � 2 r O O
,, �... that he is ezempt U�e�cfrom and tl�e basis Cor the allegcd ezempuon. Any violauon at
Section 7031.5 by arry applicant for a permit subjects the applicant w a civi] penalty of Number
�a� mo� �n� r,� n��a�a ao��� �xsoo�. 3 7 5 3 9 0� 5`�{� Occupancy Type
❑ I, as owncr of tf�e property, a my cmployces with wages az �he'v solc compensaGon,
will Co thc work, and Ihe swnu�e is not intended or offered for salc (Sec. 7044, Business
and PcoCessions Code: The Conuacwr's License Law docs not apply w an owner of Required Inspections
propeny who builds or improves thercon, and who das such work himself ar tlwugh his
own employces, providcd that such improvementa are not in�ended ar oRered for sa1e. I[,
however, the building or improvement is sold within one year of compledon, the owner-
builder will have �he burden oC proving t6at he did not btild or improvc [or purpose of
sa1cJ.
❑ I, as awner of Uie property, am exclusively conlracting wi�h licensed rnnvxtors to
conswet the project (Sec. 7044, Business and ProCessions Cade:) the Controcmr's Li-
cense Law docs not apply to an owner of propeny who builds or improvcs Uu�eon, and .
who conuacts for such projects with a convactor(s) licensed pursuant w the Convactor's
[.icense Law.
❑ I am ezempt under Sec , B dc P C for this rcason
Owner p
WORKER'S COMPENSATfON DECLARATION
I hercby �rm under penalty of perjury one of the following dectarations:
❑ I hs.�e and will maimain a Cenificatc of Conxnt to self-insure for Worker's Compen-
sation, u provided for by Section 3700 of the Labor Code, far �he pe6ornunce of �c
work for which this pertnit is issucd.
havc and will maintain Workcr's Compensation Insurancc, az requircd by Scction .
3700 oC ihc labor Codc, Cor U�c performancc oC �he work for which �his pe�mit is issued. '
My Worker's Compensauon Insurance carrier and Poliry numbcr a�c:
Carricr. Poliry No.:
CERTIFICATE OF EXEMp'flpN FROM WORKERS'
COMPENSATION INSURANCE
(This section nced not Ac campleted if the permit is for onc hundred dollacs (S 100)
or Icss.)
I cenify U�x� in thc perfortnance af tdc work for which this permit is issued, 1 shatl not
employ any person in any manncr so az w becomc subjcct ia the Worlrcrs' CompcnsaGon
Laws of Califomia. Datc
Applicant
NOTICE TO APPLICAM: If, aftcr making �his Ceni(icatc of Excmption, you shoulJ
become subjca to �hc Workcr's Campcnsatian provisions of ihc Labor Codc, you muu
� O foMwi�h comply with such provisions or this pecmi� shall 6c dccmcd revokcd.
z � CONSTRUCTION LENDING AGENCY
F+ � I hercby allirm �hat �hece is a conswction Icnding agency for thc perfortnamx of
ai � �hc wurk (or which this permit is issucd (Scc. 3097, Civ. CJ
�W Q L.cndcr's Namc '
� z Lcnder's Address ,
V � I ccrtify Ihal 1 havc rcad this application and stalc �hat thc abovc infortnaliun is �
� �—' cortec� 1 agrce to comply with alI city and county ordinances and sute laws relaong to
0 U building conswction, and hereby authori�e rcprcsentatives of this city to enter u�n the
abovc-mcntiuncd propcny for inspccuon purposes. (
�„'�,� p�,� (Wc) agrce to save, indcmnify and kecp harmlcss �hc City o! Cupertino against �
�� liabiliries, judgmcnts, casts and expenses which may in any way accruc against said City
U,'� in consequencc of the ranting o( ihis permit.
�"" APP t NT UN ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO C REGU TI N
D — —D Re-roofs
Sig ure of App i ontractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Ro��f
Will thc applicant or futurc building accupantsrorc or handlc ha•rardous matcrial
az dcfincd by the Cupenino Municipal Codc, Chaptcr 9.12, and the Hcalth and SaCcty
Codc, Scction 25532(a)?
❑Y� g� All roofs skall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainin an ins ection, I a ree to remove
Will the a�licant or futurc building accupant use equipment or clevices which g P g •
emi� harardous air conuminan�s u ckfincd by thc Bay Arca Air Quatity Managcmcni all new mat °rials for inspeccion.
Dis�ricc? "
❑ Ycs �
1 havc read dfe ha�arCous maicrials rcquiremcnLC undcrChap�cr 6.95 o(�hc Calilor-
nia Hcalth & Safcry Codc, Scctions 25505. 25533 anJ 25534. t undccs�ind that i( thc building
docs not ntly havc a n 4 Ihat it is my nsibility W notify Ihc occupant of �hc
rcyuirc n�s hichmu e riorwi ac�wrKB�oro�N�. Signature oi Applicant Date
O- —�
Owncrorawhorizcdagrni p�� AII COOf COVeC1C1gS (O be C18SS ��B or better