08120023 CITY OF CUPERTINO
BUILDING DIVISION PERMIT kCONTRA.CTORIIVQ.RMATIOAi
BUILDING ADDRESS: PERMIT NO.
10714 DEEP CLIFFE DR TBD — TO BE DETERMINED
OWNER'S NAME: PERMIT ISSUE DATE
406NR &! MRS J91IN GEIS A CONTROL NO.
ARCHI ECTIENGIHEER: B UILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u000 LICENSED CONTRACTOR'S DECLARATION
wC 1 hereby tattoo that I am licessed under provisions of CMpw 9(commmeing Job Description
IW withSation7IX10)af Division 3 ofthe Businessand Professions Code.and my license I.
^_3H in full fame and crImL REVISION,HOLDOWNS BASEMNT& 1ST FLR/SHEARWALL;ORIG
J uh Z Limnx class Lin.ff
'tgc One Contractor #08070032
r!' ARCHITECTS DECLARATION
1 undcrsund my plans shall he it as Public romme
J a.0
gi(n licensed fcssionl
5 OWNERBUILDER DECLARATION
.�<g I hereby affirm that 1 am exempt from me Contractors License Law for the
O o following mason.(Section 703 L5,Business and Professions Cade:Any city or county
3_ which requires a Permit in coxae,abou.improve,dcmoluh,or repair any awmure
_Z< prior m is issuarca.sive require thcaVplicnt faroch permit in flea signed aatamem
that he is licensed p...at to the provision of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
rEs�$ (commencing with Secdon 70(0)of Division 3 of be Business and Professions Code)or
-
that he is exempt thcmfmm and the basis for the alleged exemption Any violation of 0
Section 7031.5 by any applinnt for a permit subjects the applicant 0 a civil penalty of APN Number Occupancy Type
not moa Nan five hundred dollars(SS(l0).
❑I.as awnor oftk property.ar my employees with wage as Neo-sale cumpmamim, 356[]4009 . (]0
will do the w.&-.nd ammona eis not atendea oro@red(.,ask(Sm.7041.Business Required Inspections
and Profession Code-The Canmctore es License Law doact apply 0 in owner of q P
property who bei itis o impaves thereon,and who doessuch work hi n sv3 f or Uuaugh his
awn employees,provided that such impmvementa art not intended oroRer ad for sale R.
however,the building or improvement Is sold within one year of completion,dee owner-
builder will have the burden of proving bal he did not build or improve for purpose of
sale.).
Aw1,as owner of the propcny,am exclusively contracting wade licensed contrxbrs
camtmct the project(Sm 70x4.Bniacsa� 'o)u Code:)M Chairman's U.
cease law does not apply man reverter of p Z,0.1" Ids or impmvn Merton,and.
who comma for such pmjew wideae Ks)It d pursuant b the Combs toh
License law.
I rem exempt under Sec .B&P C far this mason
0. / Dare 12,(1. O•y .
WORKER'S COMPENSATION DECLARATON
40 I hereby alfum under Firmly of perjury ane of the fallowing declarmian:
❑I ham and will maintain a Ceadfsataof Commie toself-insum for Workers Compen.
satin,as provided far by Section 3700 of de Labor Code,for the performance of the
wart for which this permit is ivued
1 have and will maintain Worker's Compensation Insurance,m required by Section
3700 of the labor Code.for do perfoonance of me work for which this permit is issued '
My Workers Compensation Insurance artier and Policy number arc: -
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seaimt reed with,completed Btbe permit is formic hundred dollars($100)
or les)
1 certify that in the perfoonacc of- rk fit f which Nis im h u issued.l shall not
employ any perxm In an maaccr ale me subject in the Worters'Compcna0an
Laws of Celtfomia.Dan D
Applicnt
NOTICE TO APPIUCA , ter anki this Centfcate of Exemption,you should
become subject he the Wohers ComI 'on provision of an,labor Code,you mat
.J O forthwith comply with such provision or Nis permit shall be dermcd mated.
z " CONSTRUCTION LENDING AGENCY
I hereby affirm dist them is a convection lending agency far dee performase of
a de wort fur which this permit u broad(Sec.3W7,Civ.C.)
GQ Lemmes Name
:D Z Lenders Address
U O 1 mortify Nat I haw=it this application and sate Nat Ne-above information is
r comem 1 agree 0 comply with all city ain.
d county on aces and sue laws relating to
-� U building mnuucdon,and hereby orhorim representatives of his city 0 enter upon the ,
Ida shove-mentioned Property far inpecti m purposes
py (We-)agree to save,indemnify ad keep harmless the City of Cupertino against
,,i,, liabilitie,judgmenta.cosa ae d expenses which may in my wayincruc agalnit aid City
U Z ro coneguenoe of Ne gratin u permit
APPLICANT UNDE DSA O WILL
ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL TIONS.
Re-roofs
Sigwurt of Appli oe Dau
Hato fo�OUSr=building
Type of Roof
WIII the applicant o,fMuni building e.Chanuram or handle Health and
az dcRnod by the Cupertino Municipal Code-.Chapter 9.12 roti the Health and Safety
Calc,Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes WNo
Will the applicant of future building mcupani use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit bmutudnn air conumirunta as defined by tic Bay Area Air Quality Memiganoml all new materials for inspection.
Dimric0
°Ye G1 have mal the harafdWs materials mquirtmenta under Chaptir 6.95 of the Califor-
nu Health&SefetyChde,Sstimu 25505,25533aml 25534.1 containment ren Bbe Wilding
it not c nL mat it u my responsibility 0 notify dee mcuMat of be
rtyOnemcnuw 'chmu metp;artabm..r.Cadrmam 12�arOacepency. Signature of Applicant Date
n vfy
Owner arlauthbidimal. at Data All roof coverings to be Class'W'or better