02090097 M n L�
CITY OF CUPERTINO +s P Et `'v` '&'�`''�," ' ""'�': Did i •� a il• '
BUILDING DIVISION PERMIT f>CON,T,RAC-TOI2IsNFdI2MAT_ ION, Is,; ,_ „ �E" f f F
BUILDING ADDRESS: PERMIT NO
JENNECKY HOMES 02090097
PERMIT ISSUE DATE
0 NER'S NAME:
Iols
SANITARY O OL NO.
NE:
BUILDING PERMIT INFO
ARCHITECDENGINEER: BLDG ELECT PLUMB MECH
0 0 1�
10o LICENSED CONTRACTOR'S DECLARATION Job Description
E V F 1 hereby afllrm Ness I w licensed under previaimu of Chapter 9(commencing
with Section 7").(Division J ofd=Business ad I'MICoiuns Cod-.and my tic—I-
I.full force and Cffect.
License Claes LIC.. ADD 455 SQ.FT. /REMODEL
Dae f Comrsema REVISION ON PERMIT 03020060-IN HOUSE ONLY ARCHITECTS DECLARATION
I msMrnand my plena shall housed se public mcnoth
ao� Licensed Professional
OWNER-BUILDER DECLARATION
9y I hereby affirm that 1 em exempt from the Contractors License Law for LW
COC following mason.ISecdon VIJ IS,Business sot Professions Code:Any city.r county
S$ which requires•permit to censwct,Alta,borrow.demolish,of repair any smosom
-z> Pri,0its isauance,akwmquen,ft,pplicatfteauchPermit wfileasignedatemmenl Valu C
F O the,heI,licensedpntmantmthepmvdein..(tikeCa LOICOM'sLaxMICLaw(charterY Sq.F[. Floor Area v���000
E�c (commencing with Section 700M of Division J of the Business and Professions Code)or
that M is exempt thcmhom ad the beau far the alleged ostentation.Any violation of
Section 7031.5 by any aPidlem,for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mum than Ew hundred dollars(55001
01.As owner of the property.C,My employ=with wages a their Win Capcsuatloo, 36206020 . 00
will do the wmk,and the structure is not Intended or offered for at.(Sce.7W.Business Required Inspections
and Prdfoaxims Code:The Comnsctoh License Law does at apply he an owner of
property who s.proAdcd aow dsreon.and who Am notch wmk himselfm Waugh his
ownemployes,prodded Nu wch Mp,aid wi art not Intendedm Loon.freesia If. I
Witews Ne Wild inLmlmprowrovingaoldwidid ore yens of Improvtion,Neownor t Il
Wilder will Mw the Carden of proving Nat he did rest build m Improve for purpose of f G
Ask.). �'(/�i✓t
❑1,as owner of the property,an exclualwly conerealog with licensed mI.,.d s I
mnsuact the projed(See.90sa.Business and Prplaeions Cade:)TIB Commerce.Li.
mac taw docs such
pr jean owns of progeny who Wilde ar Impmw thenen,and /
whoa Law.for such projects with aconvumr(a)liunsed pmsuemmthe Conuaemh l�
71 lac Law.
❑Ism exempt under See .Bh PC fm Nis mason
wrenW o
WORKER'S COMPENSATION DECLARATION
1 hereby,Rrm under peallY of perJury One of the fallowing d-cla"Mr:
I haw and will Inwood.a Ccniftcee of Consent m self-insure for Wo,lwes CumpOm -
.OM,u provided for by Section 37M of Ne labor Cade.for the pedatmance of the
work for which this permit is isued.
1 haw and will maintain Workers CompCmuchm Iewsance.As re uir-d by Section
37W of the Labor Code,for the pedormanee attire work for which this permit is issued.
My Workers Compeomdon Inrmumen carrier end Policy number am: -
Canier. Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu secdon need Mt hecomNeted if the penal,Is role.hundred Milan($IW)
or lea.)
1 anify Net in the performance of the work for which this permit Is issued.I shall nes
employ my p-¢sen I...,manner ten As d became subjecNo the Workers Compensation
Laws of California.Dec.
Appllcan
NOTICE TO APPLICANT:IL after matin[this cmuncam of Exemption,you should
become subject to she Worker's ComPcnsellon provisions of the Lahti`Code,you must
�z forthwith comply with such provisions or Nie permit shall W doomed tswnked.
z� CONSTRUCTION LENDING AGENCY
aN IbemhyaffuIn the ft.i..co.dnn krulMl Ageaey for the perfurramle of
7 th-work fur which this permit is issued(Sec.3191.Cil C.)
W Q Isotcrs Name
z Looter's Address
U O 1 CCnify Nat I haw,sed this.1plieuion end sou:that the a Ww information u _
W t" cotmek I Agree t.comply with all city and county ordinamxs and sou laws m1niAg to
U buildingcee agree toaw.lndbyathodnept humorkllof Citi dtyocnerupon ft
Mt
W anew,mentioned pMPeny for inspection purposes.
(We)agree to mw,indemnify aha tech.11 In
to the City of Cupenst id City
it r4A
liabilities.judgement,ensu end txpenscawhich mgln soy wayattme against mid City
UZ inConsequence ofthe Swing ofthis pam,e. Date
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS. .
Re-roofs
Sigamw of ApplicadContractor Das Type of Roof'
HAZARDOUS MATERIALS DISCLOSURE
Will Oe applicant or future Wilding occupant sae rehandle hvarMm material `
As calmed by the Cupertino Municipal Code.Chapter 9.I2,and she Health and Safety
Cane.Section 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONu
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
it haaardons air conta.insms as di=nned by the Bay Am,Air Quality Management all new materials for inspection.
Olnriert
❑Ya 0N
IhewmadW h,acfi. 2550aumquimmenuunderChapsr6 ifWCalifon.
M'HeslN&SafetyCade,SCNons25N15.9351J enc 355Ja.l unthmaM thaifde Wilding
does rot currently haw a tenant.that Is u my mspomibility In notify Ve Occupant of th
-
myuimmenswhichmustWmetprimWissuanceof&CrniltcaeafOccvpancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or mlhorimd agent Dere