01090020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR-INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10367 BYRNE AVE. BARBARA GWOZDZ 01090020
OWNER'S NAME: APPLICATION SUB DATE
BARBARA GWOZDZ 09/05/2001
PHONE: SANITARY NO. CONTROL NO.
C s ZARCHITECTTF.NGINEER: BUILDING P IT INFO
m O O
y BLDG CT LUMB MECH
veul_
5 H Z LICENSED CONTRACTOR'S DECLARATION Job Description'
I heraffirm dust affithat I am licensed under provisions of Chnpren9(commencing
w1-ca with Section]0007 ofDwisian3ofthe HusimscundProfessionsCode.county license TEMP POWER.
as ei.a in fall force and effeer
6 License Class Lic.#
6 U Data Connector
u o'vHi ARCHITECT'S DECLARATION
a 1 andersund my plans shall be used as public retards '
Ill Ty
i n O O Licensed Professional
K o OWNER-BUILDER DECLARATION
ce—m 1 hereby affirm that 1 am exempt from the Confusion's Licence Law for the
(ollawfng mama(Smllon]0.315,Hubiness and Professions Code:Any city or county b.o
which q Permit to construct alter,improve mtu
demolish,or repair any stcre 'Yd
.,oto asnommic,,.N.am,fireifficpplicam for suchp to file a signed smtemem- __.� ... ..... .. _ . . . ._ _ _ ... ,...- __
O
i3m
tH t i4ak ICs. c[parstantatminni provisions oftheContractors License Law tChapter 9 ,.,� �.,y �]q pip Valuation
or
asacamiSet nm000)of he basin made, Bas ne dP fess onstelima .I-P'in
or that he isexembi therefrom and the basis for the alleged exemption.Any vipenalty
--of Section 7031:5 v any applicant fora permit subjects the applicam m a ciril'penalry'
of not roar¢man five naneree eamr.(asfu). 10 3ApN `p+ r,;04 Occupancy Type
❑1,as owner of the propeny,or my employees with wages as their sole compensation. RT.PrTRj
will do the work;and the structure is not intended mbffered dor-sale'(Sec:]UM," Required Inspections
Business'and'Prbressions Code:The ContractorR$'s License Law does not apply to an 9 p
ow
r of property Who build or improves better,and who does such work himself t
or gg e .p Iden that such improve t arc t t rid d
;offered for sale 1 wesc(Ne building or tmprovemem is sold w,thin
.no year of _ '.. .. .... .......... ...... . .._.- ._._.._.. .--_A _..-.._. ... , _' ..,".
conflictioa, wrier-builder,will have the burden of proving that he did Bat build or
improv purpose of sale.).
_.. p (Sao
proles. V p fi prem ... ... .._ . ..._.... _. _L, .. _ -
a nor-f he n I . I contracting
The
uilds or
.,and, It sLlaendep �1Tr, tvvtM1 Yl ntn,b with
B&PCfonhi'a reaston. L 51// ...._........
sed ontracmrs m
acc
c (met the t(s 7044 B d P f Cad )
L Le d s t 1 1 f n
licensed
D eri
' WORKER'S C TION DECLARATION
I hereby affirm under,armIty of perjury one of the following declarations: I ✓
❑ 1 have'find inform
a'Certifcate of Conserv io self-insure for Worker's
.n(,✓ Cmnpensetinn,--as provided for by-Section-3]00-of the Labor Code; far the'
performance of the work for which this permit is issuexl.
_ °I be and will maintain Workers Combat haturanee,as required by Section
37W of the Labor Code,for the performance of the'work'for which this permit,is
Is tl,MyW k Compensation" I dPlry mbeae,
Ciddia, Policy h 4 j j.' 1 4.. [ ail
. t `'i x4 .a x
t CERTIFICATION OF EXEMPTION FROM WORKERS l ,
"COMPENSATION INSURANCE" ...
' (this seci on ed'not oe'comple¢a if the permit is for one hundred dollars � 1 "' , ' - '
a-_
1$100)ar less)
I
' cemfya� P perform,ance f the sure fon which h s permit' et'
.hent employ'hny per in any mann¢ so s Ib becameFI tto"th,eW akrs'
ComacedLawoifminDueicant ' ':
Appl
-
'
O
'NOTICE TOAPPLICANT;If R k th Crrfcme (Exempt ymorlatild
t th h provisions or this perm e t shall be d ed k yds
ec me su]ec
Q forth th mply i
E;h CONSTRUCTION LENDING AGENCY
1 h by ffii r th t the a con t o enchg agency f theperform e
ofai work far which hisperunit is issued(Sce.3097Civ.C.)
Lender Nam ..: _,. .. _. _.,. ... _ ... -. .. . . . .. _... _..._. . .. . ..
I grey bacon ad this city
iapplicationtllatethat ances above of rm t
to 1 l agree
confir co pias hareby ity a d county, dinar d state laws er from
-V tobuildmgcodmiredon,and rlyletypact. npar,tauthorize eentdtive 1 of this citytoenmrupon -
�] the above-tmemionetl propeny let impact putpoc la „ ,_, _
,y e,. odgrai tosavesindemnifyand k hihamayj.the City ofCua.... ..saieo
Ln li try es,judgments east.and exp ase which may any y egnin t said.
U 'z Cly' mof grant J p tut
;APPk CA ;AN K LY WITH ALL NrOMPO NT" �/
souac IO S p Issued by: Date
5 tc ppli nvcamractor .. Data Re-roofs
HAZARDOUS MAT RIALS DISCLOSURE Type Of ROOF -- _ -
.., W II a ppliF t f ture railcar,nc p t or handle hazaMo m Ceti 1 ,_. ... .c.. - _
by the Cup n Municipal Code.Chapter 9.12,and the Heal a d Safety
C ae s non 25532( 7 s 1 p y . .. n .. ,..
°Ys °M1 - ._Allroofs.shall.be.inspected nor.[oars .roofing.material-being.installed _..
W ll th ppli t f t rebuJa g occupant useeq ipm t roeviea.,which If a roof iS'installed without first obtaining an inspaction,'I`ag'ree to.retitove
IR Imat hoz rdou cont t ria t as dein d by the Bay Area Air Qual ly Management
D I stri it 9 . ...
❑Y ❑No all non-point materials
for
� understands and will comply With
a new materia s or inspection. Applicant understa
;, regulanons
I havire a me h ao mu er q t u i C.1 u a 95 f to
California Health&Snfuy Cod S mio 25505 25573 and 25574 I undersea d that
iftheb Jit n cu nveat htl's my respa th'I tyt mfy -
y re of a Cemficate bf 1
heroin 'he
ch' t tp rm e
-1 Oce
p Signature of Applicant _., ._ Date
Zone,mr ammilired at Doe All roof coverings to be Class "B" or better
FFICE"