05030331 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTI2ACTORANFORMATI �^ W,
BUILDING ADDRESS: PERMIT NCO 5030331
10400 CRESTON DR
OWNER'S NAME: PERMIT ISSUE DATE
OLKEIN DOUGLAS E AND ROCK FIRS 07/14/2005
E: SANITARY NO. CONTROL NO.
ARCHITECr(ENGINEER: BUILDING PERMIT INFO
l� EO PoUMB MEC14
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�oo LICENSED CONTRACTOR'S DECLARATION lb Description
Idi 1 hereby affirm that o
al I am licensed under provinces,of Chapter 9(commencing
with Section 70(10)of Division 3 of NC Business AM ProfeWom Coda,and my llcemse 4
n in fall force sedafmm REMODEL-MASTERBEDRM/BATHROOM
jja License Clw Lk.N
Dow 1.1c.0Contractor FAMILY ROOM/REMOVED 1321 ADDITION
ARCHITECTS DECLARATION
lundemandmyplansahallheusedupuhllcmce.ds NOT DOING
Licensed Professional
^ OWNER-BUILDER DECLARATION
4 S 1 hOTn
thereby an MAI]em exempt from the Conmeaes License Law for the
p O fallowing moon.(Section FB 1.5.Business and Proreurau Code:Any city or county
8 which mqulm\a permit he coashuc4\her.Wproft,demolW,or repair my structure
prior An i4 issuance,Alm requires the applicant for such permit to file Asigned statement -
pq < Nat be Is licensed pursuant to the prevision of the Contracmr's ldceve Low(Chapter 9 Sq.Ft.Floor Area Valuation
6 S (commencing with Section 7000)ad Division 3 of the Business and Profcasioru 4 Code)m $96000
Nat he exempt therefrom and the basis for the alleged exemption.My vloladon of
Section 7071.5 by my Applicants for a permit subjects the applicant to a civil penalty or APN Number Occupancy Te
am mom than five hundred dollars($503).
P y 7P
❑I,umvnerorthepropmy,mmywploywwi0wguudctrwlecompew0on,
will do Newark,sed the swan.is not tomndcd moaamd(antic(Sm.7044,Bminw
W Profen m"Cavi:The Commerce,Limme Law don aat apply 0 an ownv of Required Inspections
property,who builds w Improves,thereon,and whocanwchworkhimaelforti rough his
own employees,provided that such Improwmentsate not intended oroQened for Ala If.
however,the building or Improvement 4 mid whom ane you of Sumpletim,the ownrn
builder will haft W burden of proving Nes he did not build or Improve fm purpose of
ia4.I.
coL u net of ct property,.B ew)us and canuecdng with:ittweC conuacwn m
cauwn tint project apply
o an Business and rty whtlos,Cade:)The Contriteness rad
actionclaw coca nm appy m ts owner of property who builds rs Improv theman,and .
who asomata for projects with aeontrsewH0lkenud punwnl to the Canmeoea
License law.
❑I am exemps under S .B @ P C fm Nis moon
WOR 'S COMPENSATION DECLARATION
1 hereby amrm under penalty of perjury one of tint following deGanOou: ��
❑Ina and will for by eCemi37M of Coasemr Coca. the
performance
cation,r provided far mi Section 3]00 of the labor Cede.fm Ne perfonnww of No
work for which this permit is isvuM.
I have and will maintain Workces Compensation Insurance.o
❑ pe required by Seaton
My Ws.Nes Compensation
pcnmmAceof the work fnumbraNis permitb Wmd. �oo�
Ca Werkees Compensation Insunnca canivand Polity number ere: [jr�
Carrie: Polity FROM
CERTIFICATE PE SATIONI INSURANCE
WORKERS'
COMPENSATION INSURANCfi
1D/jVG
(This section reed not Mcompleted Ethe permit Is forone hundred doBan($100)
or ICU.)
I certify Net In the performance of to wort for which this permit is issued,I Nell not
employ any person In soy mummer an As in mew in the Warken'Compenow.
Law,of California.
Applicant
NOTICE TO APPLICANT:IL after making Nis Cemifinm of Exemption,you Mould
become Subject m the Worker]Compensation provisions of the Labor Cede,you am
,J O faMwith comply with inch provisions;or this permit hall he deemed revoked.
„zv`v CONSTRUCTION LENDING AGENCY
r Ihereb a M.Nat Nem ts a construction kMin \C for dm
F" Y . .)ncY performance.1
C the wort fur which this permit 4 issued(Sec.7097,Civ.CJ
Landed Name
=z lender'sAMrw
U Q I caNfy,that 1 haw rod ads PplicNon And mm that the be.information is
Is.^� comma.1 agree he comply with W city and county ordinances and amm lam misting in
Q VC building construction.And hereby auNmlm mprasemadvei of this,city to enter upon do
alove-mentioned property for impaction purposes.
LL (we)agree to caw,indemnify anti keep harmless the City of Calamine against
liabilities,Judgments,cots sed expenses which may in soy way accrue against Aid City
U C•
APPLICANT cof doo annot...
UNDERSTANDS Aof IND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGtJI.ATIUT1AA
�rc ofAp(l DAM
Re-roofs
Si re of ApplicaHAZA DO Dam
'HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will them Cupertino
m future building occupant atom orhandlet heurdtwd Safety ety
u OeBned by Ne Cupertino Munidlal Cede.Chapter 9.13,and do Health and Safely -
cMe,snNnn35533(q7 All roofs shall be inspected prior to any roofing material being installed.
[3 ye, 0N
Will the applicant or future building occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hevaMow air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection. '
Dlauict7
❑Yes [3 No
I ham mad race hotrdrms mamr44 requirements under Chapter 6.95 or the Califor.
nia Health&Safety Code,Seeress,35505,35533 and 35534.1 understand that ifthe building
docs not corpora h9ma Nat 114 my mspomibility m nary Me==an of the
requirements Ma m 'mmiuuamcofaccniMmof OccuSignature ofApplicant Date
� Macy,Lfr z,j g
0 ncrarauthomada ant Dam All roof coverings to be Class"B"or better