11030025 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22306 RANCHO DEEP CLI DR
CONTRACTOR:JACK MYERS PERMIT NO:11030025
)WNER'S NAME: JACK MYERS
970 GEST DR DATE ISSUED:03/04/2011
MT.VIEW,CA 94040 PHONE NO:
OWNER'S PHONE: 6503866641
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
6REMODEL KITCHEN 100 SQ FT,BATH 200 SQ FT
License Class Lic.# REPLACE
Contract o Date 7 12 WINDOWS NON-STRUCRURAL
I hereby a,I that I am license under the provisi ns of hapter 9
(comme ' g with Section 7000)of Division 3 of the Busi. ess&Professions
Code a that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the S Ft Floor Area: Valuation:$50000
performance of the work for which this permit is issued. q
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35602044.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTIO
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lr—
costs,and expenses which may accrue against said City in consequence of the Issued b- Date: r
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.70441 Business&Professions Code).
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations• Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the will maintain is as derined compliance with the he Bay Area o it Quality
Management Chapter District
and
performance of the work for which this permit is issued. the Health&Safety jagent:
'ons 25505 25533,a 25534.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized Date:
permit is issued. �•
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's UCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby
ereb foi m t hat thishpermit is ere is a cissuedc(Sec'ending 3097, C geC j for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives-of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Date
Signature