06090038 CITY OF CUPERTINO u,�t �. a�,rad �s ,s'.a•. a� ze' a ':
BUILDING DIVISION PERMIT fa'.&9 �Abl="6T0�M,0RMAT'1 a
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BUILDING ADDRESS: JONATHAN VAN DEN BERG PERhIITNO.06090038
10026 CRESCENT RD
OWNER'S NAME: PERMIT ISSUE DATE
- JONATHAN VAN DEN BERG 09/09/2006
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ioa LICENSED CONTRACTOR'S DECLARATION Job Description
Le F 1 hereby aHm that 1 ute
n emed under provisions or Chaplet 9(commencing
inu15eame,ction 7tleff"DiviriaoSMfthaBudrevaMProfeWouCau.Wmyliccmmseu REMODEL- 3 BATHROOMS NON STRUCTURAL, NO EXTERIO
z License Class Lic.h
Dau Contractor
ARCHITECTS DECLARATION
i I undenund my plans shall M need u public record+
t6 777
°uy2� Licensed Pmfeuianal
IDJ OWNER-BUILDERexemptmDECLARATION
1 hereby affirm on I am exempt from the Contremar+ :Any c taw far the
o O Which re moann. ancon t 703 LS, t,amesa and Profusinm Code:Any city or county
Which requbes n permit re mnmsueL alcor,improv.demolish,or repair any ned statement
Zy priors,its iuvaneaaro requires;tine,inions o for sixth Committees ccomrile a aw(L umem
IZ< that he islkcucdpunuearthe pmvisiauofdeConuocmrWccmclaw(Clupur9 Sq.Ft.Floor Area Valuation
SSS (commencing with Section 7l)0)of Division 3 o the Business and Parestiom Cade)or
that he ts exempt therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant far a permit subjects,dee applicant an a civil penalty of 3AP14 MAgeru() Occupancy Type
not mom than Ow hundred dollars(5500}
0 1,u noon of the pmputy.m my wploym wed wga u deo sen eanperuadon.
will do detworkanddesuucure unotlnuumdmanemA forseerSee.7044.1lueimse Required Inspections
and Psofrmlons Code:The Contractors Llceue law doe+ane apply m u an Manof q P
property who builds or improwa thercon,and who does ane le work himsel r or through his
own employees,ismvided Nal each improwmenu am not inmsMed oroRered for cele.If,
however,the building or improwment is sold Milan 0.year efloopme0a.Me camen-
builder
il noneyearefcompletion,theewnu-
builder will have the burden of proving that he did eat build or Improve for purpose of .
sole.).
u owner of the property.am said
nuaeting with licensed connectors m
met project(See.7044.B and Pro am Cada:)The Conneemr's Li
cense la sea oat apply resp r of property
Wild,or Improwts thereon,and
who comm for such projects an acontrmloRs)1l ahead punum m dee Contractor's
License V
❑lamuc Sec ,B3PCfmthtsreamn
net Ca_v Dau 0
ORKERS COMPENS ON DECLARATION
I hemby&Rim under pemult eery o f the following deelan0onx
I have and will mean uinaCWOcomof Co dmumforwaftescompen-
sotion,in provided for by Section 3700 of the Labor Code,fu dm Performance of the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Inwtsua,as requited by Section
37011 of the labor Code,for the performance of dm work fm which this permit B Vaned.
My Wa lmes Compenution Insumncc career and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Inst be completed it the Permit is fermmc hummed dollars(5100)
or lass)
1 cenifv Not Ne p ormance of are wads for which this It a teased,I"I not
cmpdoyanype nin n anncrmasmbcrnm 'satoWorkers Co pema Mn
Law,of calira
Applicant v
NOTICE TO ICA R:I[after making this C"'acam a
sorption,you should
becomes ubj-' ro he Worker'sCMmpenutla provisions of the herCada you must
Qforthwith comply with each provisions or thi reit shall be dee d rewind.
� CONSTRUCTION LE 0AGENCY
[•+ I hereby IT.that Nee I.a comencern le agcnryforth Performanceaf
!Yi 7 tite work for which this Permit Is issued(Sec.3097.Civ,
W�Q Lenders Nurse
Z lander,Admrev
V O 1 canify that 1 haw mad this appliumion and sum Nu tit&bow:information is
I.L.— Marta,.I agree to comply with all city and county ordinances and sun laws retuing in
OV building construction.and hereby auNoriae reprosealtews allies city to crarupon the
>"a a c-mcrourcd propcny for inspcc' a.
(We)a rte to saw,indene y and keep Icss Ne City of Cupertino against
tiy li bilitiu,jud enm,cosUandex cams which ma In any wayaccmeagainst said City
U 7 in anseq of Na gmnting of 's permlL
A NDERSTANDS A WILL C MPLY WITH ALL NON-POINT Issued by: Date
s0 RCE LATIONS.
V �v 5y °� OL Re-roofs
sea m of Applicaus tum Dau
HAZAADO ATERIAISD IASURE Type of Roof
Will the applicant or Intent bee Panto r handl.hanrdou martial
u debated by the Cupertino Municipal Cao. .and 0e Heald and Safety
^ale,Septan 25533()? All roofs shall be inspected prior to any roofing material being installed.
Yea ❑No
Will the applicant or future building asapant um equfpmerl or&,I=which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air tanmminants as defined by the Bay Area Air Qmeity Management all new materials for inspection.
District?
oYd ON.
I have mad the hasardnusmar els mqu ns under Chapter 6.95 of the Califon
me side Safety Cadc,S nom,25 3,33333 VD34.1momm adthuirdu building
d net ear With. ant,Nat I my. mibility senodl'y tire occupant or the
req re ichmwtbcmet pear toI of aCestincauafOcea Signature of Applicant Date
C 9 10b o6 All roof coverings to be Class"B"or better
Owner in atthodxxi seat Dau