08080083 CITY OF CUPERTINO 7 7,77, ` -
BUILDING DIVISIONP$RIVIIT �eCONTRACTOR INF(}ItMATIQN '
Bu11.plUp25gREsN PERMIT N0.
BLANEY AVE INTERNATIONAL KITCHEN & 08080083
NEER'S NAME: PERMT7 ISSUE DATE
ROGALSKI EDWARD - 1175 E HOMESTEAD RD 09/08/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 296-3055
ARCHITECn GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Z00 LICENSED CONTRACTOR'S DECLARATION O O O
1 hereby affirm tho I w licensed disk,provisions of Chapter 9(comment. Job Description
4 rlNseed.7")ofDivision 3efNeButdoessand Pml-,j ggeandmyrenmis MODIFY EXT WALLS IN FAMILY/LIVING RM,ADD NEW
❑„ mOiliense Lies 7g WINDOW OPENING & FURNACE & A/C
j la Date w
F„ Da¢ CSDECr
ECrRCHI'IECTS DE CLIg.}
e�u I mscrsund cosi pias coal he used u public recorm /mss 9000
s C t; Likewd Prefessionai
5 OWNER-BUILDER DECLARATION
1 hereby ellirm that I an exempt from the Contra oris Licerse Law for Use
no follOWing mYnn.(Section 7M 1.S,Business Nd Plefessm.Code:Any city.1..my
$� which requires a Permit to conswcL alcor.Improv,demollm,or repair my structure
–Z� prior w its issuance.slm requires dm applicant for such permit a file a signed summon
�< tlwheislicensedpursuantmdepronsimuoftheConmacmfsLicenseLaw(Chapux9 Sq.Ft. Floor Area $100 Valuation
v
$ (commencing
rempthereSection r andtfDasisfcm r the
theegeinessend Profwinvi Code)IX
`t Net section
u 31.5 b Nerkfmm and the bud for the alleged pplicaexcemption.Any violation of
not oro103a3by anyapplicant dollars
rs(SIM nabjxu the.pplieatm,crn penalty or p,t3tI3 Number Occupancy Type
not come Wnrnw hundred dmlua(ss00). 31630002 .'Vly' P Y YP
❑L the wort Ne prepert t.isforimendes with wagea a said
(Sec.cempwdon,
wife dofewmti and NCShe, is for NLicesIX Law ffered
LICpply?an owneeof
and property
wh on cedeThe Ce tle c on,License law aces not apply lf an owner er Required Inspections
proprtyhoces,ldsorimprovuNistpro lWwho mentri am
ainto k himalfmNreainughhcwchis
ewnemp then ping Or dulsucmentis id moue not inte�dmoRerrd Wain. -
Wilderr.Ne building orcen of pmeet is mid withinut yur ofimosefor theorrcsf
Wilder wiB Itam the burden of proving that he did not build or improv for purpose of
ale.).
1,as own of the property.w exclusively co uski ng wide licensed contractors in
construct the project(Sec.1044,Business and Profession Code:)The ContraemYs Li.
erne law does not apply m an ower of pmpeny who builds or impreres Merton,and
rho rontraku for such pojocts with s imm setmp)licensed pursuant in the Contractors
Lleenve Lawt. .
❑I not exempt under Sec ,B&PCfor i3 mason
Dam
WORKER'S COMPENSATION DECLARATION
I hereby air=under penalty of perjury,arc of Ne following decundons:
❑I haw and will maintain a Certificate of Consem m sel4insum rIX Wortds Crimper.
.It..se provided for by Section 3100 of the Labor Code.for the podmer aco of the
wort for which this pe.I,is Imrtd
❑1 have and will maintain Wallace,Comperial Insurance,u required by Semon
3100 of Nle Later Code,for the peRermance of Ne wart for which this permit is issued.
C WartehComiteado ramscurimasPolicy mb�r
Carrie. Polley No.:
ERTIflCp �OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE
tided rection need cot he completed Mite permit is forism hundred dollars($I00)
or leu)
1«sufr amt in dee petkoraIXe of tho wort for which this permit is Wool.l shell not
employ any person in any mmrmrw u m become subject in the Workers'Cumpenadoo
Laws of Califomia.Due
Applicant
NOTICE TO APPLICANT:If,afkr making this C,kr,.m of Eakmptien.you should
become Subject he the Worker's Compenwdon previsions a the labor Cade,you mud
.J z forthwith comply with such parimeM or this psnit shall W dcomed,maked.
z O CONSTRUCTION LENDING AGENCY
I heroby atrfm this there is a conwedim lending agency for the Performance of
c4> the work for which this Permit in famed(Sec 3091,Civ.C)
I<
W O nder's Name
i:L ,
=) z Undoes Address
U O 1 certify than 1 bark mad Ins sp,ii.m n and star Wt the more information is
cornett 1 agree m<emply with all city and county ordinances and sum laws relating to
SV^ building construction,ars hereby suthodx rtpmxnuuvrs of this city m enter upon Ne
�[Il above-mendond penitent for Inspection purpova
"gy (we)agree to are,indemnify and seep harmless the City of Cupertino against
fn liabilities,judgmenu.costa and expenses which may In any way moms against aid City Com'
Of the grooming Of this
U z APPPL CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG%�WS. O�A6-ioe
L�� Re-roofs
Sig..ornppbeanvice_ Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum building accdpait sort or handle institutions mamrial
a deRned by the Cupenfno Mmriripal Code.Chapter 9.11.as the Health and Safety
S25532(a)?
01 d^-",
All roofs shall be inspected prior to any roofing material being installed.
Will the.Applicant or future building oceu ant use If a roof is installed without first obtainingan inspection,I agree to remove
PP g 0 ea Air Quality
or Management
ement P
D,sirkt?conn err kmntamm, m a d by Nle Bay Area u,omvny Man.gemkn all new materials for inspection.
Ores
1 haw read dm huardws underChapmr6.95 ofthe Califon
nu Hea1N&S9cLYCPde.Satiate 1550.5.15533 and 15534.1 ursrnund NuifNe building
dMJ nen curt[ ly tam a ICIIa,11,Nat it it my maponjtilily m notify Ila oceupNt of NC
regmiremena Ikhmes hematpdormissuacaufac ardfOcpgaa6y.Jja Signature of Applicant Date
Ownerm a .nailagcm 7 ODaN All roof coverings to be Class'%¢"or better