00040092 CITY OF CUPERTINO
BUILDING DIVISIONN1 PERMIT CONTRACTOR INFORMATION:
NUILIlINO ADURFi55:� a/ ��� /4�� PERMIT NO.
APPLICATION SUB DATE
ONE �� SANITARY N0. CGNIROI.NO.
ZO ARC IITF,CT/ENGINEER: BUILDING PERMIT INFO
6a � O , R 11 Ii1LF r •PL I MIi
G oLICENSED CONTRACTOR'S DECLARATION
_ 1heren affirm thanIamlicensedunder fchater9 Job Deserip on
0 z— 0 nrnvnimma n p (aammm�eing
P� with flat face
and of Division 3 of the Bupinca and l'rafaxions Codc,and my license
Id Lin full force and officer
icense Class I.ie.a
v�;'i- Datc Contractor
ARCH]'I'E(Sr'S DECLARATION N
1 unmtm
deJ may pL ns shall be used us public records U Kr
oO Licensed Professional
�� tIWNER-BUILDER DECLARATION
uai-m I hereby action t t from Comrude,'w License I..fill the
allowing reason,(Seat.. fYr an Ver e: yc ounry
O hich I quires v permit I mmstmc6 vl ran mu . rt air re o
u°i3$ priorm its issuance also F, Qi the app s nu attic d Sig state t
that he is licall putsu . it alio the Cr mmar m L 1Chapt 9 E ..Ft. Floor Area Valuation
lcommmcing with Scci 91X 1 if Divi Soft on 'ons •) -
or that he I%exempt the roan an J the r the excm n. inn
of Section 7031.5 by un cant for n uhj s the vpthe Io ivil y
ar net mere man fiaen sect. Ft
Number Occupancy Type
°I,us,..a,of the pnspcny,or my employees with wager m the, al open, a
will do the work,and the structure is not intended or offered for salt sea.7(W4, I Required Inspections
Business aad Profession,Cade The Commeamr's License Law does nom apply m an q p
owner of proproy Who mild,o,improves thernm,nmd wha discs such work himself _
m through his own emphoyces.provided that such impmvemems ere nm intended or
offered for sale.IL however,the building or impmwcmnent is wild within one year of
completion,the owner,builder will have the burden of proving that he did not builder "
as prove fm purpose of sale.).
A/L Los owner of the property,am exclusively contracting with licenced contractors to
/ nstmcm the project(Sce.7W,painless and Professions CrAa:)The cemmctar'x
License Law does erny m u
app ° nr ownerorprnperty who II improvew thmaon,
and who contracts for such projects with a cummdor(.$)licensed Pursuant to the
'mractoh License Law.
y1 um c tun I Sec._ B&P C for this reason
0 ( 'oma
t V KL+R'S C4 ATION UEC.A Air
1 hereby affirm under penvlry of perjury one of tM following dedvrmions: t ^ _ •
4ciani,en,tal.a.
I have and will maintain a Cenilicam of Consent to self-insure for Woder's
ns provided re, by Section 3901) of the Labor Code, for the /
perfomsunce of the work for which this permit is issued,
°1 have and will maintain Worker's cmusemation Insurance,as occulted by Section
3900 of the Labor Cale.Grr the peromila ce of the work for which this actual Is
issued.My Worker's Compensation Insurance cmmerund Po lay number ma
Currier; Palley No.: - �p
CIiRTIFICATION OF IiKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section head hilt W cantphmed if the permit is Sir one hundred dollars J
(SIM)or pa[.)
I molly that in the performance of the one for which this permit is issued,I
shall all nnploy any pemou in any otanmwr so as m bee°ou:saah,t ,,the Workers' I✓✓/sss"����G.. -
Compansmion Laws°r California.Date
Applicant 7 I�
NOTICE TO APPLICANT.If,neer making this Cenificase of Exemption,you should
hwome.suhjeet us mhc Workeror it,'s Compeasmin l pct tacklers oLabor Cade,you must
Q forthwith comply with such provisions or this permit shall M:deemed revoked.
(~ ` CONSTRUCTION LENDING AGENCY
as ; I hereby vllinn that there is a conxtmciion lending agency lin the perkoweinee
,fine work for which this permit is issued(See.3099,Civ.C.) -
Sin pander's Name
Z;, z Lender's Address
U 0 1 codify that I have read this application and state that the above information is
Izo (•" correct,I agree m comply with all city and county ordinances and state laws relating
0 V to building coast rumlon,and hemby mthon,awpaeent,ivesof this city to anal upon
�, k7 the above-mentioned propcny far mapmtion purpuws.
W 1We)agreet rtvm hollowly and kap hanmless @e Cry of Culmnim agnium
mFi tA liabilities,judgments,casts and expanses which may in any way vccaue against said
V .Zn City in consequence(it the gaming of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued Iq$
SOURCE REGULATIONS. y Date
Signxlaw of ApplicanalCamrafmr Law Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupamt start or handle hmmd°es material Type of Roof
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)?
°Yes ex N° All roofs shall be inspected prior to any roofing material being.installed.
Wlu the ItTlioamorfuture bnimimgoecup:mntuse egwpmentordevices which If a roof is installed without first obtaining an inspection, 1 agree to remove
•mit haamdous air contaminants as defined by the[lay Area Air Quality Management
hwtrmt9 all new materials for inspection. Applicant understands and will comply with
ova "° all non-point source regulations.
I have read the sonorous materials requirements under Chapter 695 of We
California I Iculth&Safety Coda Sections 25505,25573 and 25534. understand that
ifgrsaot requi ants which maw o t prior i ce of a Canifim¢ofm Signature of ApplicantDate
,edagem nate All roof coverings to be Class `B"or better
OFFICE
CITY OF CUPERTINO g &'*=-'a w,y z = fir- s< a^Cd, mv?ip >�w
BUILDINGnvlsloN PERMIT CON7RACTORINFORMATION
BU ILDING ADDRESS: BARBARA GWOZDZ PERMIT NOO 0040092
OWNER'S NAME: PERMIT ISSUE DATE
BARBARA
NE: SANITARY NO. CONTROL NO.
ARCHMCf/ENGINEER: BUILDING PERM ITINFO
BLDG ELECT PLUMB MECH
?SOLICENSED CONIRACnOR'SDECLARATION
mF I hereby alum that 1 am Beheld ander and
Pref ssof Chapter 9 my ficcnemg Job Description
?Zasf with Scction]IXIU7nf Division Sof NC Business and Profession Code,and myliccnse is
><n mra0mneandeffect. SINGLE FAMILY DWELLING
t nn i Co.Licclass u,a
aro Dale Contractor 1358 1ST FL, 761 2ND FL, 1065 BASEMENT
'• `,]' ARCHITECTS DECLARATION
2 m< 1 understand my plans shall be used as public Merida 400 SQ. FT. GARAGE
eau
pG Licensed Professional
g OWNER-BUILDER DECLARATION
aI 1 hereby affirm that I am exempt[rum the Contractor's License Law for the
00 following reason.(Section]113 L5,Business and Profossions Code:Any city or county
<m which requires a Permit to counteract.aIle,improve demolish,nr repair any sl u tor,
poor b)iR issuance.also requires the applicant fur such Permit to Glc aligned statement
< that he is licensed pursuant to the provisions of the Connector aLlcenscLaw(Chapter 9 Sq. Ft. Floor Area Valuation
eF0 (commencing with Section]0110)of Division 3 of the Business and Professions Cade)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of $311831
Section 7031.5 by any applicant for a permit subjects Ne applicant a civil Penalty of APN Number Occupancy Type
not more Nan five Wridned dollars($541 P Y YP
1,as owner ofthe property,or my employees with wages as their sole compensation, 35712029 . 00
will do Ne work,and the amemre is not intended oroRered for sale(Sec.7044.Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Ins ct O $
ALED
property who builds or irep rvaC thereon,and who docs such work himself or Outright his
own employees,provided that such impumvinenu are notintended or offered for Sale.If. 101 — FOUNDATION DEC 0 5 2002
however.the building or improvement is sold within one year ofcrmpletion.the owner-
builder will nave the burden of proving that he did not mild Of inflation for purpose of 102 - PIERS
a'I 103 - UFER
❑Las owner of et prnpeny,am exclusively professed..
with:)The
convectors m
oasCease La the project(sec.o an Business and Profession cadet)The eonuxmr's u- 1 04 — REBAR UI�'N{7
whoLawdoes r such apply loan itha orprapers who sedplds rrimt Loth Nerern,ars 105 — ANCHOR BOLTS
who conoacrs for such pmjecu with a conmanor(s)liccnscd pursuant m the Contractors
License Law. 106 - SEWER & WATER
❑ tato exempt antler See. .BePefor this reason 202 - UNDERFLOOR PLUMBING
owner Date 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION
I hereby of on under penalty of perjury one ofthe following tleclaratinn: 204 — UNDERFLOOR FRAME .
J Ihave and will maintain aCertmcateofeonsentwa<lhnarefor workcrscompcn- 205 - UNDERFLOOR INSULATION
`/ Saturn,as provided for by Section 3700 of the Labor code,for the performance of the 301 - ROUGH PLUMBING
work for wmmthis Permit isissum. 302 - TUB & OR SHOWER
❑1 have and will maintain Worker's Compensation InanOM,as required by Section
37M ofthe Labor Code,for the Performarec of the work for which this permit is issued. 303 - ROUGH MECHANICAL
My Worker's Compensation Insurance canierand POGeynumber mc: 304 - ROUGH ELECTRICAL
Cartier: Policy No.: _
CERTIFICATE OF EKEM MON FROM WORK ERS' 305 — FRAME
COMPENSATION INSURANCE 306 - HOLDOWNS
This sexton need not no Completed it the permit b for one handred dollars(slro) 307 — INSULATION
I CCrS.7 308 - SHEETROCK
employ cenify Nat in thein any maneera the work four which this permit is issued.1 shell nut
Lawof nyperson Dally manncrsn as to lrsome sabgnmtic Workers'eampenSation .309 — EXTERIOR LATH
Applicant
of Californias Dam 310 - INTERIOR LATH
ppncant
NOTICE TO APPLICANT:If,alter making this Cenifieate of Exemption,you should 311 - SCRATCH COAT
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J z forthwith comply with such provisions or this Permit Shan be deemed revoked. 3 13 — ROOF NAIL
?'0 CONSTRUCTION LENDING AGENCY 402 - TEMPORARY POWER
F" I hereby aRrm that there is a construction lendingfour
alenc r the performarecar 403 - GAS METER RELEASE
tx the work for which this permit is issued(Sec.709'!.Civ.C.)
i^p Lenders Name 501 - FINAL ELECTRICAL ENERGY
J z
Lenders Addre<s
502 - FINAL PLUMBING ENERGY
U O 1 cenify than 1 have read this application and surae ccs and
above information rellating to
ry bonen.1 agree to comply with all city and county naLiKsOf and Cute laws relating to 503 - FINAL MECHANICAL ENERGY
O V bonaingernstrvnlomand fe inspechmlm represenutivcs rr Nis sty mentor apon me FIN BUI LDI G ENERGY
above-mcminncd Property Tor inpcction purlwscs.
F lL (WC)agree to save,indemnify and keep harmless Nc City of Cupenino against 0 5 FIN L
Uh liabilities,judgmenu.cosu and expenses which may in any way accture against said City 5
Z in consequence of the granting our this permit,
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5NG Date
SOURCE REGULATIONS.
Re-roofs I CAL
srenaram ornrpGCanUContranor Date 5(19 — INAL GRADE
HAZARDOUS MATERIALS DISCLOSURE Type ofR O - FINAL PLANNING
Will the applicant or future building Occupant store or handle horsrdous material
as dcfired by the Cupni
err Municipal Code.Chapter 9.12.and the Health and Safety 514 — FINAL PUBLIC WORKS
Code,Section 255330)?
❑Yes 0 N All roofs sgq%beinsFic1Nq kgicBl9pII,y7Ms-Egg material being installed.
Will thea applicant of future building Occupant use e If a roof is6"lled vg 000 fig bft aXiiiii fiction, I agree to remove
PP g p equipment m devices which
it hazardous air conuminadm az dcGncJ by Nc Bay Area Air Quality Management all new mA®ills €or 1b QbtioBATTENS
markt?
❑YC1 ON. 604 - ROOF IN—PROGRESS
1 have real Ne hnnrdovsmamrials mquimmenu untler Chapter 6.95 of the Califon
nix Heald&Safety Cal.$6Gon 25515.25533 and 25534.1 umicrsund thatif the building
does not currently have a tonan,that it is my mspunaihility to notify the rccupont our Nc
requirements which must be mel Poor to ofa Certificate of Occupancy. Signature Of Applicant ]gate
Owner or aulhorired agent Date All roof coverings to be Class "B" or better