04120008 CITY OF CUPERTINO - ,- kt s.�-� x *"
BUILDING DIVISION PERMIT CONTRACTnR=IINFORMATION
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BUILDINGADDRESS: ` ROBIN SUNG PERMIT NO 04120008
21593 CASTLETON
OWNER'S NAME: PERMIT ISSUE DATE
4mM CHRIS JERBIC 5946 BOLLIN
E: SANITARY NO. CONTROL NO.
(408) 257-1827
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG 0 ELS PLUMB MECH 0 0 0
y O j LICENSED CONTRACTOR'S DECLARATION
w❑ 1 hereby affirm that 1 am licensed under provisloos of Chapter 9(commencing lob Description
iW wife Section 70M)of Division 3 of NC Business andl Professions Code.and my license is
j Lf? inmefarceaneeffea. REVISION--FRAMING DETAILS
License Class Lic.Is
?�6 DakeCamrumr NO NEW PERMIT ISSUED / ORIG. #04100061 - - -
tj ARCHITECTS DECLARATION
Y C-i 1 undermind my plans shall W used as public reamds
�yU
3 LL H Liccned Professional
S OWNER-BUILDER DECLARATION
I I fo rchy m0om that I .exempt from on.Conuacmfs License Law for the
00 fallowing reason.(Section 7031.5.Business and Pmlcadoes Cade:Any city or county
y2 ff which requires a Permit to construct.alter,improve,demolish.at repair any swans
,;tO prorto its issuance.also reyuircs the applicant for such room it to file aligned statement
that he is licensed pursuant to the provisions of Nc Commoner's 13canse law(Chapter 9 Sq.Ft. Floor Area Valuatio$115
.�o (commencing with Section 7")of Division 3 M the Business and Professions Conde)or
_
that he is exempt Nemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit ubjects the applicant o a civil penalty of APN Number Occupancy T
not mope NnY YPe
an fom hundred dollars S!Oy. - P
p 1,as nwnef of the property.or my employees wife wages as their sole comparison , 35618059 . 00
will do the work.and the structure is Out intended or offered for We(Sce.7014.Busircss _
and Professions Code:The Communities License Law dices not apply to an owner of Required Inspections
m
ppeny who Wildsar improves daemon,and whodoes such work himself of through his
Own employru,provided Nat such improvemtnss are not intended or offered for sale If.
however,the building or improvemenus sold within ane you of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of - -- ---— --_ _ -..
a1 ). E�
1.as owner of she See.property,.B exclusively convecting wife licensed contractors to
f n scum des not (Seco in Business and Professions ds or i The Contractors Lid
cove law dos not apply to in owner ofpmpenY who sed p or improves dameon,and
who contracts Law.for such pmjecu with a convsemr(s)licensed pursuant m Nt Convanoh
License Law.
❑lam uemplu er Sec ,B h P C for Nu reason
/9 wo I -� ;z / U
RK ENSATION DELLA ATION
I hereby aflhm under penahy of perjury ane of following declarations:
have and will maintain a Cen fora e,of Coven,to self-Insure for Worker's Conniver.
as pfovided far by Section 3700 of the labor Code.far the perfarmvtee of the - -
work for which this Permit is issued.
I have and will maintain Workers Compensation insurass required quired by Section
3700 of the labor Code,for Ne performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed iDbe permit is for one hundred dollars(Sim)
or Ices.)
I cenify that in ds,performance of lie work for which this Permit is issued,l shall not
employ any person in any mannerso as to become subject to lbe Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the LaWr Code you must
.J'Z foMwith comply wife such provisions of this permit shag W doomed revoktd.
Z OCONSTRUCTION LENDING AGENCY
PI hereby affirm that Vert is a covwetion[ending agency for the Performance of
C the work for which Nis Permit is issued(Sec.3097,Co,C.)
lid Q Lender's Name
z lender's Address
U C) I certify Nat 1 have read this application and stake that tht about information is
U. P aorreeL I agree to comply wish all city and county ordinentte and state laws relating to
0U Wilding construction,and hereby authorim representatives of this city to enter upon tM
IJ.1 above mentioned 1.saveroperty for inspection purposes.
(~ gy (We)agree m cast,indemnify and keep harmless the City of Christmanaen s against
h Iia consequence or
uang expcnsu which may in any way acrotic against said City
U,Z A consequence of fee granting of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUMOY. XN.
CATIONS.
Re-roofs
Si raplinUConuacmr
HAZARDOUS MATERIALS DISCLOSURE baa Type of Roof
applicant car future building Occupant some or handle ha udous material _
as dee Cupertino Municipal Code.Chapter 9.12,and�calon and Safmy
ado5s3z(a)? All roofs shall be inspected prior to any roofing material being installed.
[�Nu
If a roof is installed without first obtaining an inspection,I agree to remove
applicant car future building by ffic B y A equipment or Mann which g
air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
,Ir
XNu
I have sad the hvafdnus materiels requimmems under Chapter 6,95 of the,Calif.,
as Heal th S SafetyCoce.Section 255115.25533 and 25534.1 understand Na if the Wilding
does not emremlY haw a tetnnx Nat it is on,risponibilitY m notilY de occupant of the
requircmtnavw icttmu be mel Prior it)isavaneeofa Ceninca¢af�upancg Signature of Applicant Date
2
.OWO40lkhlmz.ad Sgend Date All roof coverings to be Class"B or better