08040129 CITY OF CUPERTINO ..a
BUILDING DIVISIONPERMIT CONTRACTQIINFORMATION..
BUIIDINCLADDRESS: PERMIT NO.
6708 JOHN DR TBD - TO BE DETERMINED 08040129
OWNER'S NAME: PERMrf ISEUEDATE
SANITARY NO. CONTROL NO.
ARCH=/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION Job Description
u F gX
I hereby affirm that 1 am li¢naed under provision esCrl of Chapter 9(commencing P
m`f with Section7l)ofDivivan3ofNCBusinwaMProfessions Cade.and mylicense is ADDING DECK AT DOOR, ' REMDL KITCHEN, EXISTING
_=m in full rose and cfr
ILI ucrnx .1 _ Lic.y SUNROOM CONVERTED TO HABITABLE SPACE
F q Own Contncwr
e 7W RCHITECTS DEC R
U I understand my plans shall be used u public records
k u. Licensed Pmfndonal
OWNER-BUILDER DECLARATION
E I hereby an.that I am exempt from the Contractors license law for the
i O O following reason.(Sortie.7031.5.Business and Rofecunn Code:Any city or county
$ which requires a permit to contract suer.improve,demolish.or mpair any structum
iy prior to its issuance.also requires the applicant for such permit to rile a signed suemem
iG Sq.Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractors Uccum law(Chaptn9
y (commencing with Seeuon 7000)of Division 5 of the 9usinns and Professions Code)or $68000
Q R$R that he u exempt therefrom and the basis for the alleged caempuan.Any violation of
Section 70513 by any applicant for a Most sobjecu the applicant to a civil penalty of -Occupancy Typenot mm them five hunaea daltus(g036923006 .,W
❑I.u owmr of the popertY,m mY employer¢with wage as the'p vele comperuuuon.
raid dofedom ands: he cortunoes Licaenoronemd(abasicpply in0as,ons.o•
and eny wh on Caere:The m Vernon.Li^"`Taw ton ml apps to an ower or Required Inspections
properlywho Wilds &d thavnch imrveaets arnot mounted imxlrm Waugh his
man cmplayen,prug or i 0th such improvements tient imm�aWardfernd'be. B.
however.the building m improvement is sold within one year of completion,the ower-
builder will have the Wdm of proving that he aid not WW or improve for purpose of
axle.).
1,as ower of me property,am exclusively contracting with licensed contractors to
construct the prom(Sec.7044,Business and Pmfeaiam Code:)The Contractor,U.
cense Law der not apps W an owner of property who builds or improves thereon.and
who compacts for such projects with a....,(a)Rased pursuant to the Contractors
Lianx law.
O l am exempt under See ,B k PC for Nis reason
caner Date
WORKER'S COMPENSATION DECLARATION
1 hemby¢Runt under pewry of perjury arse of the following declamations:
❑1 have and will maintun aCenirinm of Cataxnt m self-irpurt fmWmkera Campen-
sWon,as provided for by Section 5700 of the Labor Coate.for the performance of the
work for which this permit is issued.
0 1 have rod will maintain Workers Compensation Instrroce,as uegwsed by Section
3700of the Labs Code,for the performance ofthe wort fmwhich this permit Is issued '
MyW. Comm.auan:7.nnia and Policy nu be
Calls �/Y -F/�'s^d Polity No.: S -2W
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITU section need not x completed if dm permit is Toro m hundred Oil=(SIM)
or fns)
1 certify pmt in the Mr...of me work,for which Nis permit is issued,l shall not
employ any person in any manorso a m become srbjnt to the Worked Compen den -
Laws of Califomia.Daus -
Applicant
NOTICE TO APPLICANT:If,&nor making this Certificate of Esemption,you should
become subject be me Workers Compensation provisions of she Labor Code,you most
.J O forthwith comply with such Provisions or this permit shall he m
deccd revoked.
'Z..'y CONSTRUCTION LENDING AGENCY
[—i 1 herehy ahem dual mere is a com rection lending agency for the performance of
fx the woh for which pus permit u issued(See.5097,Civ.C.)
1 A Lenders Name
z Lenders Address
U O 1 anify ma I have reW W. pplicaim and sate Jut the above idomuum is
it,Fconed 1 29=W comply wish all cis and county on in.nas and sum laws relating 0
C)U Wilding construction,and hereby authorize taprnenutives ofthis city to enter up.use
r I27 shove-mmuonaddgm properly for inspection purposes
g1. (Wc)&Stan to save,indemnify and keep harmless the City of Cupertino against
rn liebili actism judgments.costs dna expensed which may in any way acorue¢Sint said City
U z troon
AnPPnsege U EgMANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date - eta --G S,L
RCEREG ONS. V'� r
Re-roofs
Signa of ApplionVConuenor perm
HAZARDOUS MATERIAALS DISCLOSURE Type of Roof
Will eraapCupo err future Wilding .rant store2. mnale Hudonmaterial
as defied by she Cupcnie Municipal Code.Chapser 9.13.rod the Hexlm CLW Safety
Calc.Section 25552(.)7 All roofs shall be inspected prior to any roofing material being installed.
Cl Yes ro
If a roof is installed without first obtainingan inspection,I agree to remove
Will me applicant or future building occupant six equipment or devices which P
emit havadon air contaminants as dcfrmd by the Bay Ama Air Quality Management all new materials for inspection.
Distim7
❑Ya C rs(rr�
I have read the hosadmama trials requinemenu under Chapter 6.95 of the Califer.
nuhicilthk Seen.25505.25555 and 25534.I undersand matdthe Wilding
docs mu ncnRy lfa c a�meernCO®ia u my respomibility W notify me occupmt of sir
resist nu ch hemetdr nuuanaof.Cc%tr.WofOavpas.Y. Signature ofApplicant Date
All roof coverings to be Class'%{
Owner tut miz' ¢gem g a,or better
— C