08020017 CLG
TU,of c DPvEisorvNO PERMIT CONTRACtiTQR INFUY2MATI0N
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BUILDING ADDRESS: � PERMfT NO,
10564 N BLANEY AVE TBD - TO BE DETERMINED 08020017 .
OWNER'S NAME: PERMT ISSUEDATE
• JON CROCKETT 04/14/2008
]NE: SANITARY NO. CONTROL NO.
ARCHI ECrfENGINEER: BUILDING PERMITINF'0
ADD 327 'BATHROOM,WLK-IN BO EO PLUMB O
t o o LICENSED CONTRACTOR'S DECLARATION ebesi�T' "Job Description
rg
F 1 hareby arm Ne[1 am licensed under pmvisions of Ch[piv 9(commencing ^^^^•• P
i¢ wire Section7d.fleset. ion3af NC Hutintasand Pmksdans Code,ad mylkense is
<<�y in full face and effect
,q3
Uca
DL..se Ile.• 1
q Dau Conuanar
7W .A0.CHRate DECLA ATION
� < I un amend my plane[M1.II he W osW as public tecnw
i U
uW S Licensed Pmfessimid
OWNER-BUILDER DECLARATION
J�% I bcmby of ns that 1 am attempt from We Communes License law for We
!M2 fallowing moan.(Section 7051.5.Sminces and Professions Code:Any city or..aty
is watch rand as•penal,W eonsoum,alar,bnpm c.damolub,m natal,any smmmre
Z p, prior m its iuvace,also requires me applicant forsuch permit to tilt a signcM sutament
that he Is licensed pursuant W We provisions of We ConmcWr's L'nunse Law(Chepty 9 Sq.Ft.Floor Area Valuation
(commencing with Sued.7000)of Division 3 of the Business and Professions Code)or
thu he ls exempt therefmm and We buss for,the alleged eeapdma My violation of
session 7051.5 by any applicant for a permit subjects the applicant Let civil Penalty of - APN Number Occupancy Type
not awe dun five hundred dollars(55110).
❑I,as ownerafLupmpeny,or myeroploym with wage utheuakcempomdon.
will do the worle.nd the swaum is nmktaMed or offered frrule(Sm.7004,Bust•... Required Inspections
and Prefeuiam Cadm
Carla:The CuenU..r's Ulaw data cot apply W owner an of q P
property who builds tar impmvea thereon,and who does such wart himself m through his
awn employee,pravldcd thin such improvements arena Intended molfesed furnace.if,
howev O.We building or Improvement u said within aro year of completion,the owm-
builder .will have the intake of proving dw he did not build ar Improve for purpose of
sassy
❑I,as awner of the prapany,em exelusitedy...Waiting with licensed car=.to
common the project(See 7014,Businces and Profusions Cale:)The Coovacmr'i Lim
came Law does not apply W an owner of property who builds at Improves theme..,tad
who contuacls for such projects with.eontnnat(s)0car ad pursmm W the Conoacur's
Lieena law.
❑1 ren exempt under See .B A P C for this,coon
Owner Due
WORKERS COMPENSATION OECIARATION
1 Lately a07m under penalty of perjury am of We following declamti ms:
lh[mad will maintain a CeNEeuaf Camera to self-hume,for WmuYa Compare
.on .as Provided far by Section 57M of the labs Code.for We performance,of Wa
work for which Wu permit is issued.
❑I have and will maintain Worker's Compensuion Insun n x,as required by Section
5700 of the Labor Code,far We performance of We work for which thin permit is issued. '
My Worker'[ ampradon Inwuace nnier and Policy Lumber Mef:�',.vx
Cartier. Policy No.: ls—I�D"kD,r'
CERiHFl •O EKEMPIONFROMWORKERS
COMPENSATION INSURANCE
This actum read Out he Lu m filmed If We pcmit Is for em hundred do0.a(31 W)
or loss.)
I ccrdry that in We performance of We work fm which this Permit is issued,l dull am -
employ My Person in any mamser a as to hecome subject in do Wwkc&Compensation
Laws of Calif..[.Data
Applicut
NOTICE 7D APPLICANT:If,oltar making this Certificate of Exemption,you should
become subject W the Worker's Compensation provisions of We Lalmr Cada,you most
�p foMwime.mplywithach provisiommthupemitshall bedeamW ravoli .
ti.Nr CONSTRUCTION LENDING AGENCY
I hereby affirm Wm mea is a commatm lending agency for We picrformance of
x.>-t We work fm which debt permit I.issued(Sce,5097,Civ.C.)
31 Q Leadeh Name ,
7 z Lender's Add.
J Q 1 certify that 1 have mad Wis application and suss that We above irdomadun Is
y',••'. comer I qnm W comply with W city and county.Ninames and suss lows relating to
Wilding convection,and hereby summun mpmaontadves of this city to now upon We
127 above-mentioned property for inspection pugmsas
(We,)agree to save,indemnify tad keep hamlets 0e,City of Cupertino against
SCM Iiabilides,judgmenu,emu and expense which may in anyway amue gains.said City
JZ in camequenee of We igu MZL Issued by: Date
APPLICANT UNDERSTA S A D WILL COMPLY WITH ALL NO -POINT
50 ULAT,ONS
41/A4 Re-roofs
Siuumu AppliranUC manor 'I Dim
HAZV[DOUS MATERIALS DISCLOSURE Type of Roof
Will the applleanl or lotwe building mcupml store or handle harudaus material
as de0nod by We Common Municipal Code.Chapter 9.12.and the Hcalmh and Safety
Code Section 25552(.)7 [�� All roofs shall be inspected prior to any roofing material being installed.
❑Yta t n.
Will the eppliawnm.r taloa building occupant era equipment m dcvima which If a roof is installed without first obtaining an inspection,I agree to remove
OIL ho'raaam air contaminants its unfitted by me Bay Arm Air Quality Ms tat ire., all new materials for inspection.
Diurict7
El Y.
Ihavemad the hamdonsmateriaemquiremcnuun ,Chapkr6.95oftheCalifor-
nuHulWd:SafmyC.do,Sadmu25505.25533u M5M.Iu d deatifdc building
docs not cumndy hem•amort,dm it ls my m[pomiMlitY W norify me occupant of m
Knz=*
hicLa metpdarWhoomme.r.cemifK.ta.r Signature of Applicant Date
owner or anmm <d tat ata All roof coverings to be Class"/¢ or better