07100060 CIT�' OF CUPERTINO ' ' ` '
BUiLDING DIVISION PERMIT e�����T�� X��a��`�'T ':
. .. .
:.. : : _ , _
PERMI'I' NQ.
BUILDING ADDR£SS:
10619 LA RODA DR TBD — TJ BE DETERM�NED 07100060 •
PEItMIT LSSUE DATE
JNER'S NAME:
DON & TERI PHILLIPS 10/31/2007
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT iNFO
ARCHI'I'ECT/ENGINEER: BLDG ELECT PLUMB MECH
� � � �
� Z LICENSED CONTRACTOR'S DECLARAT[ON ' ' -
� � I hcrcby afGrm that I am ticcnscd undcr provisions of Chap�cr 9(commcncing JOI] DeSCIlFItlOfl
z � with Scction7IXXT) of Division 3 of Ihc Business and Profcssions Codc, and my license is EXTND 2 ND FLR TO ADD BEDRM & BTH � PULLOUT 1 ST FLR
�� in full Corec and eCfect ��. � ENTRNC & ADD UTI LITY RM . REMDL EXI STNG 2ND FLR
� � ? Licensc Clazs
� F , � oa�c ARCHITECI'S DECLARATION MSTR BL DRM � MSTR BTH & EX STNG 2ND BEDRM . REMDL
i� a 1 undcrswnJ my plans shall bc uscd as public rccords
�yU
' u. E' Licensed Prufesaional
; � < OWNER-BUILDER DECLARATION
���
1 hereby alTirm U�at 1 am cxempt Crum �hc CoNraaors Licensc w or thc
� p O (ollowing rcason. (Secuon 7031.5, Busincss and Profcssions Codc: Any city or county
�°, �''i which reyuires a pertnit to canswc4 a1�t. improvc, dcmalich, or rc�.tir any swcture
�—'� prior to its issuancc, also rcyuires thc applicam for such permit ta filc a signcd su�mcnt Valuation
. Z ,. Ft. Floor Area
< that he is ]iccnscd pursuant lo thc pmvisions oC thc Contractor's Liccnsc Law (CJiaptcr 9 S9 • $ 2 7 5 0 0 0
%[_-� �(commcncing with Scction 70D0) of Division 3 nC �hc Busincss and Profrssinns Codc) or
?�� ihat he is exempt the�ctrom md the basu Cor the allcgcd eumQuoa Any violation oC
Section 7031.5 by a�ry applicant for a permit subjecu �he appficant to a civi] penalty of (] �] Number Oceupaney Type
nol more than fivc hundrod dollazs (5500). 3 6 7 3 J O[ 8�� �
0 I, as owner o[ ttie property� or my employces with wages az their sole compensation,
vr;;dothework,aaCthes�2ctu�isiotintendedoroffereQ ��Ci ;;ired Inspeciions
and Pmfessions Cade: The Canuacwrs License Law dacs not appty w an ownu of
property who 6uilds or improvcs thereon, and who does such work himaelf or tAmugh his
uwn employccs, provided �hat such improvements are not imended or oRued for sale. IC,
however, the building or improvement is sold within one year oC compleuon, d�e owneo-
builder will have the burden oC penving that hc did not build or improvc for puepou of
sale
`1 , as awner of the property, am exclusivoly contracting with licensed conuacwis to
�,f wct the pmjea (Sec. 7044. Business and Protcssions Code:)'ILe Caotnctnr's Li-
ccnse !,w docs not apply w an owner of properry w6a builds or improves the�eon, and .
who conuacts for such projects with a conuactor(s) licensed pursuam in Ihe Conuactor's
' icense Law.
I am u t under Sec . B dc P C for this �eason
� � Jwner Date _ .
WORK ' OM CLARATION
1 hereby affirm under penalty of pe�jury one oC the fallowing declarations:
❑ I hsve and will maimain a CutiGcate oF Conunt to sdf-insum far Workct's Compen- �
sation, u provided for 6y Sectinn 3700 of che Labot Code, Cor the pedarmance ot the
work for which this pertnit is issucd.
❑ I have and will maintain Worker's Compensation Insunna. ac rtx�uired by Scction .
3700 oC the Labor Code, Car the pertormance oC the work far which �his permit is issued
My Worket's Compensation Insurdnce carricr and Poliry numbcr aze:
Camer. Policy No.:
CER7'IF[CATE OF EXEMP'170N FROM WORKERS'
COMPENSA'i'ION INSURANCE
(Chis scctian necd not bc complctcd if t6e permit is for one hundred dollus (E 100)
or 1cssJ
I certify that in the performance of the work fw which ihis pertnit is issue4l shall not
employ any person in any manncr so cf bje;t to the Workcrs' Compensauon
Laws of Calj'Fetnia.
Applicant
NOTICE � CA . If, f�r making this crtifica�c oC Ezcmption, you should
bccome subjcct �o ihc Worker's Compensation provisions o[ �hc Labor Code, you must
� O forthwith comply with such provisions or [his permit shall bc decmcd ccvokcd.
Z � CONS7RUC170N LENDING AGENCY
[...� r. I hcrc6y aftirm �hat thcre is a conswetion Icnding agcnry lor �hc perfortnancc oC -
{X, � thc work (or which this permit is issucd (Sec. 3097, Civ. C.) ,
4=1 Q Lendcr's Namc
a z LcndeisAddress
V � � certiCY lhal I havc rcad Ihis application and su�c that thc abovc infortnatiun is
�� cortcc� 1 agrce to comply with all city and coun[y ordinances and sutc Iaws relating �o
rJ U building conswction, and hereby authori�e representatives of this c�ty to cnter upon �hc
,� W abovc-mcntioncd property for inspccuon purposes.
a (We) agree to save, indcm�ify and kecp harmless �he Ciiy oC Cupcnino against
H � tiabilities, judgments, costs and ezpenses which may in any way acrne againsl said City
(� z in consequcnce oC the granting of this permit. Date
"'� APPLICAN'I' UNDERSTANDS At�(D LL COMPLY WITH ALL NON-POINT Issued b�i: O J
R ULA17 S. �
Re-roofs
ign u c of A p i �C ntractor Datc �/
HAZARDOUS MATERIALS DISCLOSURE Type of : Zoof ;
Will ihc applicant or Cuwre building occupant stom or handlc hvardous matcrial
dcfined by the Cupertino Muni�al Codc. Chap�cr 9.12, md thc Hcalth and Salcty ,
�odc.5cction 25532(a)? � AlI roof:; shall be inspected prior to any roofing material being installed.
0 Ycs -
d if a roof is installed without first obtaining an inspection, I agree to remove
Will thc applicant or turc building occupant usc cquipmcnt or dcviccs which
emit harardous air contaminants as dcGncd by the flay Area Air Quality Managcment ail new � naterials for inspec*ion.
DisvittT �
❑ Ycs
1 havc rcad the ha�ardous matcrials requiremcn�5 undcrChaptcr6.95 o(thc Calitor-
nia Hcalth & Salcty Codc, Scctions 25505, JS533 and 25534.1 undcrs[and thazif thc huilding
docs noi eurtently havc a tcnan�, tha� i� is my responsi6ilily to notify thc occupam n( thc
rc' cn�s which must Q� � issuancc of a Ccnifica�c of Occupanry. S 1gI1SCllL ° of Applicant " Date
� V All roof coverings to be Class "B or better
wncr or authon�.ed agcnt � ���
CIT�' OF CUPERTINO Y � ` 7�T�
BUILDING DIVISION PERMIT t%����`���� ����`
_ s . ;:= . ..:
` • '
PERMIT NO.
BUILDING ADDRESS:
10619 LA RODA DR TBD — Tc) BE DETERMINED 07100060 •
PERMTT LSSUE DATE
dER'S NAME:
DON & TERI PHILLIPS 10/31 2007
SANiTARY NO. CONTROL NO.
PHONE:
BUiLDING PERMIT INFO
ARCHITEGT/ENGINEER:
BLDG ELECT PLUMB MECH
� 0 0 �
i p p LICENSED CONTRAC7'OR'S DECLARATION JOI� DeSCflptlOfl
'� I hcrcby aflicm thai I am liccnscd u�uler provisions oC Chap�cr 9(commcncing
';Z wiihSccdon700U)o[Division3ofthcBusincssandProfcssionsCodc EXTND Z:�TD FLR TO ADD BEDRM & BTH� PULLOUT ZST FLR
�� y in f�ll forcc and cftec[.
��z LicenscClass [.�c.� ENTRNC x ADD UTILITY RM. REMDL EXISTNG 2ND FLR
i� � °a1C pRCHITECi'S DECLARATION MSTR BD �RM � MSTR BTH & EXSTNG 2ND BEDRM . REMDL
7 a 6 1 undcruanJ my plans shall hc uscd as public recnnls
)yU
° a F' Licensed Pmfcssianal
: � a OWNER-HUILDER DECLARATION
j a� 1 hcrcby aCGrm �hat 1 am ezcmpt from ihc ConlraMOrs Liccnsc Law for thc
. C O following rcasoa. (Sectian 7031.5, Busincss and Pro(cssions Calc: Any city or county
�°�, � which rcquires a pertnic to consuvct, altcr, im{xovc, dcmolich, or repair any suucwrc
� Z y prior ui i�s issuancc, also tcquires thc applicant for such permit ta file a signai s�atcmcnt Valuation
< Wa� hc is liccnscd pursuant to thc provisions oC ihc ConUactur's Licrnsc Caw (Chaptcr 9 iq. Ft. Floor Area $ 2 7 5 0 0 0
� F� (commencing with Scction 7000) of Division 3 oC �hc Busincss and Profcssions Cadc) or
°�� that he is exempt thcicfrom and the buis Cor the allcged eumption. Any violauon o[
Section 7031.5 by arry applicant tor a permit subjecu �he applicant to a civil penalty of Number Oceupancy Type
not more Wan five hundred dollars (5500). 3 6 9 3 3 0 2`3 ��
❑ I, az owncr oC ttie property, ar my employces with wages u their solc compensauon,
wili do �he work and she sttuctu�e is no[ intended or offered for saic (Sec.7044. Businr;; Required Inspections
and Professions Code: The Conuacwr's L'uence Law docs not apply in an owner of
propecty who builds or improvcs thercon, and who does such wwk himsel[or Uuuugh his
own cmployccs, providcd ihat such improvements are not in�ended ur ollered Cor sale. [f.
however, the building or improvement is so�d within one year o[ complcuon, �he ownerv
builder will have the burden of proving ihat hc did noi build or improvc [a pmpose of
��
� , as awner o[ ihe propeny, am ezctusively contwcting with littnsed conuxtors w
�, wct the project (Sec. 7044. Business and ProCessians Code:) Ttie Coatnctor's Li-
ccnse Law docs not apply to an owner oF propertY w4o builds or improvrs Idaeon. and ,
who contracls tor such projects with a conuactor(s) licensed pursuant w �he Convxtors
License Law. , B& P C for Uus tcason
t� �x t under Sec.
r � �„� Date _ .
WORK ' OM CLARATION
I hereby affirm under penalty of pe�jury one o[ the following da�Jaruions:
❑ I hsve and will maintain a CeniGcate oF Consent to self-insure for Workers Compen-
sation, az provided for by Section 3700 of the Labot Cade. far the performance of the
work for which Wis permit is issued.
❑[ havc and wi11 maintain Workers Compensuion Insurancc, u rcquired by Scction
3700 oC the Labor Code, for the perfortnance o( �he wo�ic for which �his pecmit is issued.
My Worker's Compensation Insurance articr and Policy number azc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPI70N FROM WORKERS'
COMPENSA'C[ON [NSURANCE
(This section necd not bc canpletcd if the permit is for onc hundred dollars (5100)
or Icss.)
I cenify that in thc performancc of thc work for which U�is permit is iscucd. 1 shall not
employ any person in any manncr so �sl�befg�n�bje�t to the Workcrs' Compensation
Laws o[ Cal' �a. //// //
Applicant � ��J'� � �'�'S
NOTICE CA . If, ftcr making this�rtiCca�c of EzcmpGon, you should
bccome subjcct to the Worker's Compcnsadon provisions of �hc Cabw Codc, yau must
� O forthwith cpmply wi�h such provisions or this permi� shall bc dccmcd ccvokcd.
z ""' CONS7RUC'f10N LENDING AGENCY
F r .�-� I hcrchy a[firtn �hat ihere is a conswctian Icnding agcrrcy 1or thc performa�e u[ _
(Y, � �hc wurk for which this permit is issucd (Scc. 3097, Civ. CJ
[t7 Q L.endcr'S Namc
a � Lender's Address
V � ( certity tha� 1 havc read this applieation and siate that the above infortnation is
��--" cortcct. 1 agrce to comply wiih all city and county onlinances and su�e laws relating �o
rJ U building conswction, and hcreby authori�e represcn�ativcs of this city to cntcr upon thc
� a abovc-mcntioncd property for inspccuon purposes.
(Wc) agrce to save, indcmni(y and kecp harmless ihc City of Cupcnino against '��
„F„ � liabilities, judgmcnts, casts and ezpcnscs which may in any way accruc against said City
V z in consequence oC the granting aC ihis permi�. DaLC
►�+ APPLiCANT UNDERSTANDS AhjP LL COMPLY WITH ALL NON-POIM Issued by:
E R ULATI S. �
Re-roofs _ /
ign u of A p i UC nvactor �°� T of B.00f -�"
HAZARDOUS MATER[ALS D[SCLOSURE }�� .'
�11 �hc applicant or futurc building occupantstore or handlc harardous matcrial
cfincd by We Cupertino Mun�al Codc. Chaptcr 9.12, and thc Hcalth and SaCcty
.x, SccUon 25532(a)? � All roofs shall be inspected prior to any roofing material being installed.
❑ Y� •
Wlll thc applicant or wrc building accupant usc cquipmcnt or dcviccs which
If a roof is installed without first obtaining an inspection, I agree to remove
emii harardous air conuminants as dcfincd Ay thc Bay Arca Air Quality Managcment all new rr.aterials for inspec*ion.
District? n � /�
❑ Ycs ��196
I havc rcad the ha�ardcws ma�crials requircmcn�s undcr Chaptcr 6.95 of �hc Califor-
nia Hcalih & Safcty Codc, Scctions 75505, 25533 and 25534. I undcrs�v�d ihat i(ihc building
docs not curtcnlly havc a tcnant, tt�at it is my rcspansi6ility w nodl'y thc occupant o( �hc
rc' n�swnichmusi p' � �u����orac��r�a�oro�,�P��r. Signature ofApplicant Date
� All roof coverings to be Class "B" or better
wncr or authonxcd agrnt Da�c —