04120050 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT ;CONLR°ACTQ .INFO.tMATION ;
BUILDING ADDRESS: V DON CONSTRUCTION• ;:•. '" PERMIT N004 12 0050
10843 MINETTE DR
OWNER'S NAME: PERMIT ISSUE DATE -
Aftga MELVIN & .PAMELA RA13ECK 1469 AMBERGROVE DR . 12 /op /2no4
HE: SANITARY NO. CONTROL NO:
(510) 882-2404
ARC HITECDENGINEER: BUR.pING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S DECLARATION
i U� 1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Business and Professions Code.and my license is
infull fares,and effeeL REVISION--IN HOUSE USE -ONLY�41 - -- ' _-
Z0DamueChis uc.gn, Convector
— NO NEW PERMIT ISSUED/ ORIG. #04030138
—O Da
ARCHITECTS DECLARATION
< I undersand my plans shall he used as public records
Dau
o Licca ed Professional
3 OWNER-BUILDER DECLARATION
,�<I I hereby affirm that 1 am exempt from the Contractor's License law for the20 following moon.(Seed..7031.5,Business end Psofessiam Code:Any city or county
K m ff which requires a permit to convruct,altoan
,improve,demolish.or repair y much.
Fiy prior to is issuance.also requires the applicant for such Permit to file a signed Moment
££xx<
that heislicensed punoan to the provisions of the Contractor's LiwnuLaw Chapter 9 Sq. Ft. Floor Area Valuati($115
NF$ (commencing with Section 7a W)of Division 3 of Business Businand Professions Code)or
— that heu eumpt Nuefmm and the basis fest the alleged caratMy violation of _
Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of pith Number Occupancy e
not mart than five hundred dollars(1500). 37532059 . 00 p yTyp
❑1,as owner of the progeny m my employes with w gas u ftb mle compensadon,
willdo the work,and Nestrucw¢isnot intended oro@rad formula(Sec.7(X4,Business
and professions Code:The Ca drachd s Licence law does ret apply to an owner of - Required Inspections
,rope.,w M bunds m improves thereon.and who d«a much work himaclf or tiw.gh his
Own cmployau,provided that such improvements an,not intended oroffe ad forsale.If.
however,the building or improvement is and within one year of completion,the owner. - ---
Milder will has the burden of proving that he did not Mild or improve for purpose of
salt.).
❑1,as owner of d¢property,am exclusively contracting with licwed contractors to C \
construct the project(Sec.7044.Business and Professions Cade:)The Contractors U. O
cense taw dad not apply e m owner of properly who Wilds ter trimmer demon,and.who contracts for such prolacea with a comnctor(s)licensed punor ant to Ne Commoner - V
Lies.Taw.
I sum exempt under See. ,B A,P C for this won
0 r Dan,
WORKER'S COMPENSATION DECLARATION -
IherebyafflimunderPenaltyof perjury one of the fel C-1-__1
as:
have and will maintain a Certificate of Continuo self-insum for Workers Camper- - - -
sstian,u provided for by Sttsion 3700 of the labor Coda for Ne Performance of the
wants for which this Permit is issued.
10
I have and will maintain Workers Compensation Insurance,as required by Section
37W of thc labor Cade,for the performance of the work for which this permit is issued. _
My Workers Compuwdon Inamence carie and Policy number are: - —
Carrier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sttarm need not ocomplea l lithe Permit is forom hundred dollars($100)
or less.)
1 certify Nat in the Perfomence of the work for which Nis Permit is issued,l shall not
employ m,person in my manner Out as to become subject to tM Workers'Compensation "
Laws of California.Data
Applicator
NOTICE TO APPLICANT.If,after making Nis Certificate of Exemption,you should
became subject to Ne Worker's Compensation provisions of rhe labor Code.you must
.J Z forthwith comply with such provisions or this permit shall M dammed sawkcd.
Z O CONSTRUCTION LENDING AGENCY
PI oreby aRrm that then is a conswction lending agency for the Perfurmanca of
cd> the,work fur which Nis Permit is issued(Sec.3097,Ci,C.)
CQ Lender'Name
:) Z Lender's Addw
U O 1 certify that 1 have read this application and sate Nat the move information is
UL F" c.recL I all to comply with all city and county ordlnancer and area laws totaling to
Oral building conarrumnon,and bombs audarim representatives of this City to enter upm Nc
Gahwe-mentioned pmPcny for inspection whichmpurposes.
(We)agree to save.indemnify and keep harmless Ne City of Cupenino against
h incomonecofa,eosa Lideapeuer which may in enY sway acerae agaivt aid City
V z mcausequNT of Nc darting of Nu L.
^ APPLIC.gNT UN ERSTA 5 AND W LL CO LY WITH ALL ON-POINT Issued by: Date
SO R gREGUL TI NS.
Re-roofs '
n orcof Applicanucunuumr pen,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or f.mre Wilding occupant atom orhandlc huatdous material
u defined by Ne Cupertino Municipal Code.Chapn,r 9.13,and Ne Health and Safety
code.SeeMres n 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or fto building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Wha knJous air conuminants u dcfincd by the Bay Area Air Quality Management all new materials for inspection.
❑Yes �N.
v
1 have mad the Women rs mahcrials requiremen s under Cbmm,6.95 of to Calif n,
ria Health A Safety Coda Secons 8505,25533 and 25534.1 undersand Nat if the Wilding
dons n c.—ytiy haw a enanL that it L my respouibility a nosily do mcupam of Ne
m whkh a of a Cenificaa of
C Signature of Applicant Date
.da i.<d age p,a All roof coverings to be Class •'B"or better