07060249 CITY OF CUPERTINO '°'�" "'�'^•'"� ''}"' r.�xau'
BUILDING DIVISION PERNHT "CONTRACTOR INFO,rRMATION,,
i
6u1LQIly,GGLpQµEsMPI RE AVE TBD - TO BE DETERMINED P07U6U249
l U l tl.7 PERMIT ISSUE DATE
OWNER'S NAME:
RICK BLESZYNSKI 01/03/2008
PHONE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
'rRCHITECTMNGINEEk:
BLDG ELECT PLUMB MECH
38Zp LICENSED CONTRACTOR'S DECLARATION Job Description
td I beteby game Nat I Am licensed under poevlaboss of Chapter 9 rmmfood seamiwu ng HOUSE DEMO
with S �70flu)of Division ofWusiness Band Profassias Cade,Andre lice
a H in full face and effect.
q Z_ License Clea Lic.A
Dam ARCHrrECrS DECLARATION
t 1 understand my plans NII he used As public mcWds
s W Licensed Prefwi...i
y0� OWNER-exempt faDECe RATION
Conuel
N
i C I Wmby Affirm Sec Nal I I.S.exempt s menan the Comon,CO License Law O for do
❑O following moon.(Section 71n LBusiness and Pmfictinns Code:Any oily a rounsy
$f! which mquirns a permit W Warts,Alter,bmpmve.demolish,or repair any struclum
zy prim At its issuance.also mquiresthe Applicant for such Worth toriileasignmAgandanl Ft. Floor Area Valuation
that he is licensed personal to ac provisions of the Conoactai License Law(Chapter 9 SQ. $8000
$ (cammencing wait Section 7000)or Division3 of Ne Business odd Protections Codc).1
that be is eumpl Nuefmm and as,basis for the alleged eaempdon.Any violation of
Section 7031.5 by any applicant far.Permit Wibjees the applicant in a civil penalty of 3 2 6 2 2 0 2 9 AM Number Occupancy Type
nut mart Nan Rw hundred doll.($500).
❑1,as owner of the pmpmy,ar my=Play=wIN wages As their sole Compensation.
will do Ne wail,and the scum en is not intended of offered for sale(Sm.7014,Business Required Inspections
Add Pmfcssi.Code:The Conuamr "»
s LI^- Law does nit apply W in Owner of Q p
pmpeny,who buil&or impmwstimnvn,and who doessuch work himaelfor Waugh his
awn emplo,ma,proM&d Nat such bmpmwmens Am not roadbed Wuppertal(orale.if.
howewa the building or Impmwmmt Is Wild within arc your of Wasi edon.Ne course-
Wilder will ban the burden of proving Out M did set Wild W maiden,for purpose of
alk.)./
&4.u wm of the pmpeny.We taelusWely conducting with account sadamaged,W
construct the Project(Sec.7044,Business and Profesdans Code:)The CooOactoes U-
cow law does not apply in an owner of property who builds or Impetuous thereon,ad.
who Mmncu far such projects with a mnuscue(s)accused Pursuant to the Capri
V4n,.
pexempt under .B&P C W Nia e
Owuer�jL rBX+ ww1Iw_
Data
rst O
WORKER'S COMPSgJfATION DECLARATION
1 herby afRre under faulty of perjury arc of the fallowing dx doses
1 haw and will maintain a CaNgnes of Conant to self-insure for Wmidn'.ComPen-
Iru provided fed by Section 7700 of are LAW Cade.for Ne Performance of an
for which this permit is iaued.
❑I haw and will maintain Wahers Compression Insu goo.As required by Section .
3700 of the I-bW Codifed Nc perfecto..of the wotir fed which this permit is baued. I, '
My Wtudae,Comp rna0m Inarance artier ad Policy number tie:
Carrier: Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
C7hisnced.reed mtbecanplaud athe permit is finenc handed dollars($100)
or less)
I attify Not in Ne'f.macpff amp��y W which Oi$Permit is Woe .l slim not
empLaw lq a rein ay mat EFF
abject m do WorYeri Compensation
Appluc CSlifa- It �i
Applies ,Jell —
NOTICE TOAPPLICANT.1 afterm.tlng this Cenonsof of FLAW code,you
,
hmomeabjectm it Warrant's pre Compensation previsions of theLAWCode,. most
vJO tanhwith comply with such ryoviaians aro this pprmitshall be domed revoked. )
? CONMUCf10N LENDING AGENCY
C4
[-n I hemby afrom ant than is a construction lending agency for the perfutamce Of I
0.' > ac wart for which this Perth u issued(Sec.3097,Cl,.C.) -
W Q Lendcrs Name '
z Lenders Address
L)0I certify Om I Mw read this application ad sum ON dm Allow information is
(•' Martel.I agree an comply with all city ad county aNinacea and sum taws misting In
O fJ buildin( ewgreeto ad.mica authand i prose lmthedm au citymenterupnnree
W abaw-mentioned Property for inspcnian purpaes
(WC)gree to caw.indemnify and hap harmless the City of a &Lasts spurt
Iubili0eadeam"Wnu.emu and cep....t which may in ay wad aeeme agaimtsud CllY
L) n uace of as gtmting of this Permit. Date
APP NDERSTANDS AND WILL COMPLY WITH LL NON-POINT Issued by:
SOU ONS.
G1at: Re-roofs *L
Signatucaf ApplianVCon car L Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will No applicant or future Wilding occupatso=Wheedle hasNom material
As&Rad by Ne CupeNm Municipal Code.Chapter 9.13,and the Helth and Safety
Cade,Section 23532(+)7 All roofs shall be inspected prior to any roofing material being installed.
❑r
Will On Applicant,of future building naupant car equipmm(or devices which If a roof is installed without first obtaining an inspection,I agree to remove
'l hasftlnus air contaminants u defined by the Bay Arc.Air Quality Mantgcmcnt all new materials for inspection.
let? lw,
❑Ya ONO
I ban rum the buaNausmueriau rquimmcns under Chap W 6.95 oflhe Califm
IN&safcsyCodc.Sameres 25505,25533 And 25534.I andusund WtifNc building
dean t c ntly how•tectal.Nu it u mY maponsihilltY W notify W o¢upat ret Jun
which mug WMet prior missuance of.cwlicfoe pally Signature of Applicant Date
owner arWiaarivsd rel am All roof coverings to be Class"B"or better