B-2018-0505 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR; PERMIT NO:B-2018-0505
1566 PRIMROSE WAY CUPERTINO,CA 95014-5230(366 15 Olt) JACK MYERS
CONSTRUCTION INC
SAN JOSE,CA 95129
OWNER'S NAME: DATE ISSUED:03/28/2018
OWNER'S PHONE: PHONE No:(
LICENSEDTR C DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#63406
Contractor JACK MYERS CONSTRUCTION INC Date 12131/2018 X BLDG ELECT_PLUMB
1 hereby affirm that f am licensed tinder the provisions ofChapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fill force and effect, JOB DESCRIPTION:
KITCHEN REMODEL(115 SF);REMODEL(2)BATHROOMS(100 SF);
I hereby affirm under penalty of perjury one of the following two declarations: REPLACE(1 l)WINDOWS;RELOCATE FURNACE TO ATTIC.
n. 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
performance of the work fmwhich this permit is issued.
I have read this application and state that the above
.Information Is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 15 012
representatives of lhls city to enter upon the above mentioned property for
inspection purposes. (We)agree to save Indemnify and keep harmless the
City of Cupertino against Ilabilitles,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regula ion per the upertmo Muni;pal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 03/28/2018 Issued by:Jasmine Archbold
Date:03/28/2018
ER- V, , R TI
I here y I'Rrm tlmtl am exempt from the Conhector's T..icense Law t'm one of the RE-ROOFS:
Callmv ng wo reasons: All roofs shall be inspected prior to any roofing material being installed.If.roof is
n. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining in,inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z.
1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec,7044,Business&Professions Code). Date:03/28/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
n. 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
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. i have and will maintain Worker's Compensation Insurance,as provided for by I have read the haze dons materials requirements under Chapter 6.95 of the
Section 370D of the Labor Cade,for the performance of the work for which this California health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(n)should I store or handle hazardous
shall not employ any person in any manner se as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25 05,25533,m 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized agent:
APPLICANT CERTIFICATION Data:03/28/2018
J certify that I have read this application and slate thaf the above information is CT LENDING A
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there'q 9 construction lending a ency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit Is Issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against sald City In Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHIT'ECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 03/28/2018
Professional