06040010 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT tCOiTRACTRI INF�yORMA'TIO
BUILDING ADDRESS: MR & MRS JEFFRIES FERMITNG.06O4OO10
7529 DE FOE D
OWNER'S NAME: PERMIT ISSUE OATS
MR & MRS JEFFRIES 0 6
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
'BLDG ELECT PLUMB PARCH
ioo LICENSED CONTRACTORS DECLARATION IObDO5Cf1 Description
I hereby a(0rm Nat 1 un Ikensed caroler provial of Co.,.,9(mmmeocinj p
ith Ssdon 7010)of Dt,.1 Jafde Bedmnv Pru letters,Code,and my IIccone b
? ainrnllrortpanderre 1 STORY BED & BATH ADDITION ADD WALL DIVIDE WA
LkenmClau _ uc.gCa) 3
Dew , BETWEEN BEDROOM 2 & 4 AND DEN (417 SQ. FEET)
Con DECLARATION
1 tp�kp+ an shall CI'S DECLARATION ..>
I understand my Olma shall W used as public records
c Cleansed Professional
`ro that I .BUILDEfr m the Com ION
i c 1 moss .(tiers(Section n I am,usin from the Conoanafs License law for Ile
O O which re moon. ermito 7(131.4 Business and ve.derou Code:Any city or county
$ which requires a permit re cnnmuut.eller.nt fmve,h Permit o or rep Nr ed statement
'
iSe
prior man be
its inmm0.aivantto aNcapplwam for ouchmon'w0kaeLawkment
< (comms licensed Section 7000)
to the pm vialanaofthe the
t3ccme Law(ChaptersCode)9 Sq.FI. Floor Area Valu$019392
�m (cot he ise g pt Sectirom and or the baiiiof r M al B ed assumption.
Profion.Anlnna Cmc)of
9
that he b ettmpt Neafrom and the bub for the alleged ettmpdm.Any vlalaum of
Smdon 7071.5 by any applicam for a permit mbleclo the applicant to a civil penalty ofr Occupancy Type
rot rose Nan five hummd&Ram(SSW). 3 40�` �O
❑1,u owner of dw pmpaty,w my empwy m with vnges u thebmk mmperwdon,
will do the work,and die Muaure b nttimmMcd"offered fasak(Sec.7OW,Busineea Required Inspections
and Profaedaru Code:The Commodes Limem Taw does rot apply w an e owner of q p .
property who build&or improve thereon,and who does such work himself err through his
however.
the
I that well Impmwmanu are not Iewmm or offered for We If.
howevu.oy Wilding o provided that wmanl r mid within one Xte of completion,tlw Owner.
Wilder
wig haw the burden of proving that he did rot bulk or improve for purpose or
min.). �/
❑I.u owner of the Smpeny,aro tuess and cafieskeg with ganmd conaanors -
cmutrua d prolan apply
TOW.Business and Rofudom Cade:)The Conisacwr'a Li-
arta law coca not apply je an owner of property who Wilda or Improves,McNemo s and, j
whence Lace for such pOJeune wlNaconvacwrt&)Ilaneed DunwmwlM Convanofe
License Law.
❑lam uempt undo gee .Bde PCfor N4 mown v�•a
Owner Dale /✓'"
WORKER'S COMPENSATION DECLARATION
1 hamby&Mm under penalty of perjury one of Ile following declarukm:
137'y1)l
h&w am will mainW n a Certiricaw ofComem w self-imam for Wodrers"nomen.
,u provided for by Section 3700 of the Labor Code,for the perfortu mm of the
(err which Nu pewit is Issued.
have and will maintain Worker's Compensation Imaanu,u required by Scnian
ofthe labor Codc,fathe perfamauxofdn workrawhich unit permit bluuedorkefa Compensation Is urarce artier and PolgT number ue:er: No.:
CERTIFIC FIXEMP51O FROM WORKERS'
COh1P ICISe1d7 SURANCE
(lTbmcdon med not W completed If the permit Is foram hundred dollars(310)
or leu)
I ecrury Not k the performance a the work for which this permit is Wuce.I"I ma
employanYpemoninany muglCy0 pkua �m�mbjeclwde trn
Wor 'Compensation
lawsof Cdifamia.Daw `a l
Appliemt W'l�'
NOTICE TO APPLICANT:IL after making this Ccdi0cate of Exemption,you should
became subject an the Worker's Compenutian provlaiona of the labor Cede,You mut
wJ O forthwith comply with such provisions or this permit,hall W doomed revoked.
Z� CONsmuc ION LENDING AGENCY
IherebY M.thn ft.tsacamumdnn lending agency farthe performance of
!k
the work for which poll permit is issued(Sm.3097,Civ.C.)
4 Q landefs Naam
]Z landefa Address
U Q I certify that 1 haw mW this application and slow Nu the above information is
ly F corms.I agree to comply with all city and county oreirsnua and auk laws mining w
0 building construction,and hereby mmonm represenmiws of this city to enter upnn Ne
LU shove-mentioned property for inspection purposes
(We)agree to caw,indcmni fy and keep hmmless the City of Cupertino against
y imbillda.judgments.sew and commutes which may in my way acne against said City
U Z ineomegmtn"Of ting of Nis permit.
.. APP D STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 6a Date
S RCE R ONS.
Re-roofs
Signa o UC Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wi0 de applicant or faun Wilding e.Chapter
or handle hazardous a roaseriai
u defined by dw Cupertino Municipal Code.CGpkr 9.13.cab Ne Health and Safery
Cmc.Salon 25533(a)7All roofs shall be inspected prior to any roofing material being installed.
[3y. mNo
Will the applkam or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
telt ha'rardnus air conlommams u dc0md by Ne Bay Am Air Quality Management all new materials for inspection.
Dimi3O
❑Yca No
I have mud de WaArdmumakriabrcqulrereew umerChamer6.95 of ft CARTa-
nbHealth ASa(etyC 'ats25505,25533 aro(M34.lumcmend theifte Wilding
a cum ..We
L Nat it b my mapoaUility m mtifY de asupant of the
m Imomms is ren metpdormiuuamaora CcrdOcncof Occupancy. Signature Of Applicant Date
Owmrar utho n Dow All roof coverings to be Class"B"or better