06030161 CITY OF CUPERTINO ^' K 1;+, m�"`i's ,E_ �
BUILDING DIVISION pERMIT CON TRACTORANFORMMON g,
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BUILDING ADDRESS: PERMIT N0.
10051 S DE ANZA BLVD
R'S NAME: PERMIT ISSUE DAIS
MARDESICH COMPANY 1097 RIDGELEY DR 03/29/2006
PHONE: SANITARY NO. CONTROL NO.
(408) 879-9756
ARCHITECDPNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Soo LICENSED CONTRACTOR'S DECLARATION O O
0 1 hereby AM.that I am licensed under provisions of CWpm,9(commencing Job Description
with Section 7")of Division 3 of the Business and Profession,COCA,and my license is
In pull remnandoff
INTERIOR DEMO ONLY
14 Licence Lk,0
Con VA1 A1011 KY,
Dam ARCHITECTED CLA AT1 N RENEWED BUS LIC 3/29/06 �� �� ®
1 undeeuand my plan Nall W used As public mcords
� U
a Licensed Professional
yg OWNER BUILDERm Ce ConnsON y/qqLO06
i<f I hereby a(snn onn I am exempt from the Camns,Co License Law for the
p O which m Memo Pamir
(section 703 1.5,Business and improve.
demolish.
Cad):Any shy or county
$ which rtyulrtu•emit us cnIWNCL patter.plic improve,dcmnlrh,ri e a sig any Itactum
ivo prior b its issuance.sedpalso mquime the inions of forsuch permit to file a signed mtcmcnl
< licensed pursuant 1.Me provisions of the Contrse70r inmense Law own(Chapter Code)
Sq.Ft. Floor Area 0L, 8
atheis(communing with Section 700 0)the
basis f r M the Busaged cassand ear.Any vi Code)or
dot he r 31.5 b Ianmfrom and the aper for tie cis the emicant t.Any violation of
Sectio 7031.5 by bandiedeammr300). subjects the Applicant anvn Family of APN Number Occupancy Type
Iw1 mane than Ow hundred dolrn($500}
❑I,As Matter ofte property,or my employees with wage As their ole compensation, 35908018 . 00
will do the work.and dleawctum is not intended AT offered forsar(Sec.7014,Business
and Pnefeeion Code:TW Cmumeaces License Law d=Am apply 70 an owner of Required Inspections
property who bui Ida or im prows timmon.and who does such work himself or througM1 his
awn employ=,provided thnsuch improvements am notimmmded proffered for sale.If.
Wwewa Ne building or improvement is sold within arc year of completion,the owner.
builder will have the burden of proving that be did not Wild or Improve for purpose of
els.).
❑1.as owner of the property,am exclusively contracting with licensed controm us m
Construct the pmlect(Sec.7044.Business and Pronasions Code:)The Condamine,U.
mase law does not Apply IT,an owner of property who Wlid,or impmws Manor.and
who contracts for such projects with a eonutemon s)licenced Pursuant 70 the Conuectors
LkenAc Law.
❑lam cam"a em Sec ,B&PC fm Nr mean
r Dam
WORKERS COMPENSATION DECLARATION
1 hereby affiml under penally of perjury one of the following declars0ons:
❑]hew and will maintain sCeniEem ofCowwnt 70 selfAnum fn Warmes Campers
Action,As provided for by Section 3700 of the labor Code,rn de performance of the
work for which this permit is leaned.
❑1 haw and will maintain Workers Companedon Insurance,m required by Section
370D of the Labor Code.for the performance of the work for which this permit Is Issued.
My Worker,Compensation Intuaree carrier arm Policy number Am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENIS RANCE
IssecOnn ednmWcomp Wdl(Ihe
Ibforonc hundred dollm(glgl)
or mu)
1 unify t in th performance of the t rk to vhich This permll isherml.l shall not
employ an N in To asubjeea )Worker' empensatian
LAm.fC 'iso a.
Applicant —
NOTICE TO PLICANT:IC after making Cenificam of tion,you Naa1d
become sobjem m the Workers Compensation pmvlsion of the W ode,you mon
.J O forthwith comply with such provisions or this Permit W dm ked.
t••' CONSTRUCTION LENDING AGENCY
(,N IWmby aRnmthat them is a construction lending Agency for the performance of
FL the work for which this permit r issued(See.3097,Ch,C.)
aQ landcrs Name
z Lender's Addmas
U O I mNfy that I haw reed this application and tum that the&bow information r
I,,F conal.I agree to comply with all city and county ominemes and state laws mining to
0 building convection.and hereby authorize rcprecematiws of this city to Cris upon tW
ITl aWve. property for inspection purposes
gL (We)as to saw,in I d keep harmlus,the City of Cupertino against
fish hicsjudg net,cosuen expo mlch may In my soy mcme against said City
t.> inc mac ofthe grantin o(this On ? n
APP CA UNDERSEA S WILL COMPLY WITH ALL N POINT Issued by: Date J^L 5^-o 6 ,
SOUR E C TIONS. L
I 06 Re-roofs
Signuurc pylic HAZARDOUS
Dam
HAZARDOUS building
Smorhan l Type of Roof
WilltheMcCipantor Tonus Wlldinp upant Am or And
a Health And Safety As dcOncd by the Cupenina Munk ipel Codc. hapm 9.13,roti tW Health and Safety
PC,Section 25532(00
Yen All roofs shall be inspected prior to any roofing material being installed.
❑
Will the Applicant or atomNo budding amvpent use equipment n devices which If a roof is installed without first obtaining an inspection,I agree to remove
..it he It mntsminants U me by the Bay Area Air Quality MAAAgemcnl all new materials for inspection.
Distric
❑Year u
I haw Ad the hmam us end s requirements under Chapter ofthe Califon
ria Ith& A(my Cade.Socd 25 .25533 and 25534.1 rode thaifde Wilding
d= t cu rely he a want, t r my mibdiry m nod IW occupant or the
mqut a whit ust met missuen or cam Occupancy. Signature of Applicant Date
Owner or authoriecd agent Dam All roof coverings to be Class nBn or better