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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
tCOiTRACTR„I INF�OTIO
BUILDING ADDRESS:
MR & MRS JEFFRIES
FERMIT NO.06040010
7529 DE FOE D
OWNER'S NAME:
PERMIT ISSUE DATE
dMkMR & MRS JEFFRIES
0 6
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:BUILDING
PERMIT INFO
'BLDG
ELECT PLUMB PARCH
LICENSED CONTRACTORS DECLARATION
lob Description
P .
I Wmby drEfm IMI 1 sus lkenxed umkr prnvisoesof Chapter 9 (counce.1n9
with Section 7010)of Dividan Safde Busirmajimil Professwmcodo,and my license is
effect
1 STORY BED & BATH ADDITION ADD WALL DIVIDE WA
Lkenlw Claund
Lie. 3
Date conDECL
BETWEEN BEDROOM 2 & 4 AND DEN (417 SQ. FEET)
A DECLARATION ..>
I undcatand my plana shall W used u public cewrN
shallh used
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from IM Con sesoes License Law for Ue
following mason. (Section 7031.5, Business ted Professions Code: Any city or county
which requires a permit to construct, suer. improve. demolish, or repair soy suoment
'
prior to its issuance, also requires dre applicant for such permit in file a signed statement
the Commcwr's Mneme Lsw(Chapes 9
Sq. Ft. Floor Area
Valu 0®392
that be is licensed pursuant to de lamaons of
(commencing With Section 7000) M Division 5 of the Businessand Professions Code) or
that he is eumpt Woodland and the basis for the alleged eucepdm. Any violation of
NUT`
Occupancy Type
Secdon 7071.5 by any appliesnt for a permit subjects the applicant to a civil penalty of'
MI cents Nan five hundred dollar, (SM3
4
01,uownerofsicpropaty,"mysmpwymwithwgesutheksokwmpe don,
Required Inspections
will do the work, and the suuaum is maimeralcul"offered f"sak(Sec. 70th, Business
and Profession Code: The Commemes Lkeme LAW does rot apply w an owner of
q.
progeny who build&"improves thereon, and who does such work himself or through his
ownevu. o e Wiping o dthatw r modems are
uiprogor Improvement weblmproveceanlsarenot Intandndmofferad for McWeIf.
no Xu of completion, ered site owocf.
however. the
builder wig Mw the harden of proving that he did rot Wile or Mprave for purpose of
sale.).�
❑ I. u owner of ace concocting with amaell i-
/
TheCconucwn
a ct Sm.7 Businessand Cade:) The C,
project Besinea and 3
daemons nd
Who Wideor ImproWa daemon. and
moons d apply n an propertywise
who Law dossnot applyjean
j
ithaofpcopmY
whocontracts for such projects wlNaconuacwrta)flamed DunwmalM ConvanoYe
License Law.
❑lam uempt undo gee .Bd:PCfor 344 recon
v�-s
Owner Data
/✓'"
WORKERS COMPENSATION DECLARATION
1 thereby &Rina under paWly of pedury one of Ile fallowing declarateu:
I"v and will maintain s CatifswmofConsemw self-iunefarWorimsCompw-
aatlan, u provided for by Section 5700 of the Labor Code, for Ne performance of the
work far which Nu permit is Wood.
have and will maintain Worker's Compensetlon Insunllw, u required by Scaian
of 1
37111 f tae Lobar Code, for peff"mams of the Work for which this Permit is blued
'
My Warkees Comps wlmura cxtiu&MPoILTnumbum:
-
Canier. No.:
C 9Fd1C FIXEMPI70 FROM WORKERS'
COh1P R550N7 SURANCE
v
(TWimcdon wed not W completed If the permit Is foram hundred dollars (310)
or leu)
I certify Not to the performance of Oe work r" which Nis paceil is Wuce. l "I not
employanypersoninany mulOgyw is lq �m�wbjml w Ne W.Am'Campauulon
Laws of CalifamiatDue `
_
Applicant
NOTICE TO APPLICANT: IL doer making the Ccdilicne of Exemption, you should
became subject an the Worker's Compensation provisions of the labor Cods you must
forthwith comply with such provisions or this permit shall W decreed evoked.
CONSTRUCTION LENDING AGENCY
1 M.by affirm that Nem e a calmr"tinn lending agency farthe pufofceanw m
the work for which the permit is Wind (Sec. 5097. Civ. C.)
'
l Landers Name
fandces Addeo
I I eenify that 1 have read this application stud! sum Nu the above informuen is
COMM I agree to comply With all city and county ordinances and sue laws meting in
building construction, and hereby mmonto representatives of this city to enter upon the
shove -mentioned property for inspection purposes.
(We) agree to vas, indcmni fy and keep hamlets ths City of Cupertino against
liabilities. judgments. most tad expenses which may in soy way usres against said City
in conscquelee of sing of"
f Nis permit.
' APP D STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:6Date � y
S RCE R ONS.
Re -roofs
Type of Roof
Signu o UC RDam
HAZARDOUS MATERIALS DISCLOSURE
Will ft appiloss,"fmuni building hurudomceaerial
e. Chantuore"Mndk
u by du Cupertino Municipal Code. Chapter 9.13. and Ne Health and Safety
"e Oc
Cade. Seems25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes LTJ No
If a roof is installed without first obtaining an inspection, I agree to remove
'� Will the applicant at future Milling occupant use equipment or devices which
Ott he dem als contaminants u defend by Ne Bay Area Air Quality Management
all new materials for inspection.
Dimi3O
❑Yes No
I have real de huudaucealaiatsrequireceem utderChaper6.95 of ft CART"-
neHm1th,kSahuyC ism 25505.55533 and 25534. I wdcnund Nu if Ne Wilding
OK cunt ..We L Nat it k my reapomUility w wtifY da asupant of the
m Imomms k rot metpdormissummofa Ccrtificaeol (lccupucy.
Signature of Applicant Date
All roof coverings to be Class I'BI' or better
Owner" atha Date