05090004 CITY OFCUPERTINO
BUILDING DIVISION PERMIT
,,CONTRACTORTNFURMATI01
BUILDING ADDRESS: PERMIT N0.0 5 0 9 0 0 0 4
10339 BYRNE AVE
OWNER'S NAME: FERMITISSUHDATE
ANDY DEBAETS/BECKY SMITH 01/25/2006
,yE: SANITARY NO. CONTROL NO,
ARCHTTELTIENOINEER: BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
3Oo
LICENSED CONTRACTOR'S DECLARATION Job Description
4 I hereby affirm that 1 am licensed under pmvi+imna of Chapter 9(commencing
with Section 7011U)ofDivmlon 3 of the Businnse and FrolesAu-Cade.and my limen a is
in full fame and effect. SFDWL-2 STORY (2516 ' -LIVING SPACE)
i'�?o Data cl°" Contractor BASEMENT-451 ' /GARAGE-451 '
D ARCHDT.CI'S DECLARATION
I undarmnd my plane sell he used u public words
sed
Licensed Pmfcuianel
'
OWNER-BUILDER ArmDECLARATION
1 Wrathy Matc.(Sad..
that 1 I.S.exempt from the Contras Co License Law for the
p o following muoa(Section 7(131. Business and Professions Code:Any city or county
$� which requires•permit m cnnnitucL+lee improve,demolish,or repair any structure
pdar o its Issuance.Alan requires the applicant for such permit to Ne asigned statement Val &B3 9 3
<
that he isHccnxd forwent m the provisions ofthe Conuecure.Lima.Iaw(Chapter 9 Sq.Ft.Floor Area
�$ (commencing with Sachs 7000)of Division 3 of the Business and Professions Cade)or
- that he is exempt therefrom and the basis for the alleged exemption.Any violatlan of ppb N b7e� 0 0
Smim.7031.5 by any applicant for a permit subject,the applicant to a uvll Faculty of 3 5 712�ml Occupancy Type
am nut mthan Ove hundred dollars(5500).
❑I•u owner of the pmpmy,w my employm withcages u thalr mle compensadon,
will do the work.and theauuctum is not intended orortered for We(Sec.7044,Business Required Inspections
and Professions Code:The Comontor's Liadoes not Law donal apply o an curator e q p
pmpeny who builds or Improv a Barron,andwha does suc h wort himself or through his
own employees,provided that uch Improvement,are nminended araRerad(orale.If,
however,the building or improvement is mid within one year of completion,the owner.
builder will haw the burden of proving that M did an,build or Improve far purpose of
isle..
Vu owner of the propeny am eulusivaly contracting with licensed cuntmahms o
causunct the pmjm(Sec.7044.Business and Profession Code:)The CmiruoYa V-
come law does not apply m an owner of propmYwhn buil"or improv therms,and, .
who convects for such project,with a conrranor(s)licensed pursuant o the.ComoattoM1 ,
License Law.
Cloth.a mplp undo Sea (��, �- B&P C for this moon
••mer t(Wt�_t�iL-.C� V �rs�w-gA _ Data
1 LS D�x
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ma of tie following declandmn:
I law etM viii matnuin•Cenifiwa of Consam o self-buum for WorWACompcn-
ution,as provided for by Section 3700 of the labor Code.far de performance of the
work for which this permit B issued
❑1 have and will maintain Workees Compensation Insurance,u required by Section
3700 of the Labor Code,far the performance of the wart for which this perm,is iuusd.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
trials section reed Out Wounpleed lithe permit is foremc hundred dollars($100)
or leas)
1 codify met in the performance of the work for which this permit is Issued,I Nall not
employen rano loan an aa!! �l�pWoMe Wrj.1 retia Workers'Com neNon
Las f California.ifppa¢ )3-5�"`w j K
App lkant �,.M,e,.7�$fkv-
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Coda you must -
.J 0 forthwith comply with such provisions of this permit shall be deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
[.w 1 hembyaRum this then is a commaxtinn Imakagagcmcy far ft performance of
the work for which this permit is issued(Sec.3097.Civ.C.)
W�Q Ianhor's Nurse
7 z Lenders Addrm
U Q 1 certify that 1 have mad this pplication and sou that the show Information is -
U.!' correct.l agme to comply with all city and county Measures and sum laws mlating to
C)tr.^J building construction.and hereby authmim representatives of this city to enter upon the
W above-mendoed property for inspection purposes.
(We)agree to sew,indemnify and trop harmlm the City of Cupertino against
y liabilities judgments.cuts and experuca which may in any way amus agama a id City
U Z in consequence of the granting of this permit. .
sew APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINr Issued by: Date
SOU REGULATION . f
� i 140(a Re-roofs
Signature of ApplicanUCanuacmr Dama of Roof
HAZARDOUS MATERIALS DISCLOSURE Typ
Will the applicant w too=building ocmpanumm or handle hundous material
as"fined by the Cupertino Municipal Code.Chapter 9.13,and fact Healon and Safety
Cade,
Section25533(a)T All roofs shall be inspected prior to any roofing material being installed.
❑res pie
Will the applicant or future building Occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huardaus air contaminants as"Rued by the Bay Amo Air Quality Mmagemcm all new materials for inspection.
DiurinT
Yu u
I haw read the hareNtnsmalerialsmquimmenu under Chapter 6.95 of the Califon
nice Health&S&IMYCadc.Sectiaw 25505.35533 od25534.1 undcmmd thuifthe building
docs not currently how a u nam,that It is my responsibility to entry ft eccupant of the
requirements which an be an t pn.am ssu of a CemOcam 0'0 c�pancy Signature of Applicant Date
S" `� "�S/ub All roof coverings to be Class"B"or better O
T
Owner or amhorimd agent Dam