04060183 CITY OF CUPERTINO '�'j T
BUILDING DIVISION PERMIT ;cONTRA.CT04U N'FORMAT10 ."k,
a
BUILDING ADDRESS: ROCKY & DONNA LOWELL PERMIT NIb4060183
10311 MANN D
OWNER'S NAME: PERMIT ISSUE DAIS
ROCKY & DONNA LOWELL 06/22/2004
E: SANITARY NO. CONTROL NO.
ARCHI7ECVENGINEER: BUILDING PERMIT INFO
' BLDG ELECT PLUMB MECH
+�oo LICENSED CONTRACTOR'S DECLARATION Job Description
Ux a 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
,; with Secta.7")of Division Sof Ne Buin)uand Professions Code,and my license is
< in fullmreamdeffea REVISION--IN HOUSE USE ONLY
5qb Dataa ciao cmetr NO NEW PERMIT ISSUED/ ORIG. #02120026
L' Data LI1.01 ser
8p ARCHIECPS DECLARATION
u-t5 1 understand my plans shall W used an public records /f
7 y `�
G Licensed Professional a g5r
5 that It exempt fa DECLARATION
I hereby moso affirm then 11. exempt from rite Contractor's License Law for the
O O following muna(Section 71131.5,Business and w.demolish.
Code:Any city orcounty
tme
u�$ which requires issuance.permit re mnstmc.alters improve,h Permit t fir repair any tatement
HZt tprior tohe,Witsenseilmmquime thovisios of forWe mchpcmr's Liteaeigne0statemem
Not me cccnsWpursuant70th)ofDivision3dmCo urines LicenseLaw
onsCod(Chapter 9 Sq.Ft.Floor Area Valuatic}�1107
$ (eat he is
(commencing Section 70DO)nd tht,Division f r M the egad e=md Professm.Any
vi Cade)of
Net he u exempt therefrom and Ne bssie for the alleged cumptim.Any violNon of
Section 7031.5 by any applicant for a Permit subjects We applicant m a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars($500). 32645043 . 00
0 1,u owneeof the pmpeny,or my employcu with wages u their mle mmpensation,
will dote work,and the structure is not intended or offered for sale(Su.7044,Business
and Prolamines Cade:The Com selor's License Law does not apply in an owner of Required Inspections
property who builds or i reprovesidimma,and who docs such work himsel f or through his
own employees.provided Natsoch improvements arc mlink bled oroRerod fmaJe.If.
however,We building or improvement is mid within one year of complcdon,the owner.
builder will have the burden of proving Nat he did not build or improve for puryo c of
ole.),
❑I,as owner of the property.am exclusively contracting with licensed contractors to .
construct the pmjecl(Sec.lCuPt,Business and Profusions Code:)The Contractar's Li-
cense law docs not apply to an owner of property who builds or improve Woman,and
who contracts for such pmjecu with a contrecur(U licensed pursuant 70 We Comnctoes
License Law.
1 am exempt under Su. .B&P C fm Nis moon
Owner Data
WORKER'S COMPENSATION DECLARATION
CI hereby affirm under penalty of perjury mm of We following declarations:
have and will maintain a Cenifeft mfComent to self-insure for WorkeseSCumpen-
aml m,On provided far by Section 37W of the labor Code,fm dm performance of We
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of We Labor Code,for Ne performance of Ne work for which this permit is Issued.
My Worker's Compensation Inst ranee carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMP71ON FROM WORKERS'
COMPENSATION INSURANCE
ffhisscction mod natio)completed if the Permit isforooc hundred dollars($1 011)
ar less.)
1 cenify Not in the performance of the work for which this Permit is issued,I shall not
employany person in any marmom az to become subject to the Workere 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 provisions of the labor Cade,you must
QZ forthwith comply with such provisions or this Permit shall he deemed nwok)d.
i O CONSTRUCTION LENDING AGENCY
F+ I hereby amrm Nat More is a construction lending agency for Ne Performance of
the work for which this permit is issued(Su.3097,Co.C.)
6Wi Q Lender's Name
Z Lender's Address
U 2
1 cenify that I have road Nis application and sum Nat the above information is
)ormel.l agree to comply with all city and county ordinances and state laws miming to
O U building can awcLion.and hereby auNodm repremmativen of this city in enter upon We
u] above-mentioned property far Inspection purposes.
we)agree b save,indemnify and keep harmless the City of Cupertino against
py tn liabilities,judgments,coats and expenses which may in my way accrue against mid City
in
of ffic Smunfing;of
his
U„Z APPLICANTeUNDERSTANDS tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signemre.fA,pIicaaWC.Wowtr One
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Neapplicantor umfuture buildinge.Chapter
mor handle Health and
u dented io the Cupertino Municipal Code.Chapter 9.13,and We Health and Sm)ty
Code,Section 35532(a)7 Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Wili the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hmardnua air contaminants a defined by We Bay Arca Air Quality Management all new materials for Inspection.
uicR
DYos ElNo
I have mad the hvamnus materials paptimmems under Chapter 6.95 ofthc Califor.
nia Hcal &SMayCadc,Sccdons 25505,25533 and 75534.1 undcumnd that lfthc Wilding
docs not conically hoe a moan.that it is my responsibility to nobly tiw pxupant of the
requirements which must be met prior to Issuance ofa Certificate of Occupancy. Signature of Applicant Date
Owner r authodaed agent Dam All roof coverings to be Class"B"or better 1