07060250CITY/OFCUPERTINO
BUILDING DIVISION PERMIT
CONCRACrUR I1 UitMA.'I', 0
n n,
BUILDING ADDRESS:
10215 EMPIRE AVE
TBD - TO BE DETERMINED
PERMITNO.
07060250
OWNER'S NAME:
PEtM17 ISSUE DATE
RICK BLESZYNSKI
01/03/2008
PHONE:
SANITARY NO. CONTROL NO.
RCHITECWENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
i LICENSED CONTAACTORSnderp DECLARATION
1 hereby a of that I sm Ilovescd under provision of Chapter 9 (commencing
lob Description
I
HOUSE DEMO
infullfameandefecDivisi0n3ofuuBudvatandProfcaviunsCadc,andmylic,vei.
( in full and effect.
a Class;
License Class Lk.g
Dam corTSowwr
DECLARATION ARCHITECTS DECLARATION
1 undmaunJ my plana Mall be used u public recants
i
{ Licensed Prokssmnal
i OWNER-BUILDER DECLARATION
I booby affirm that I am exempt from the Comactor's License Lew for the
I following mason. (Section 703 1.5, Business and Profession, Calc: Any city or county
j which requires a permit m ....tact. alter. improve, d.m.lish, or mini, any structure
Prior m its issuanc,, afro reunion the applicant rarsuch Permit to file a signed statement
that he is licensed pursuant o the Previsions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area Valuation
1 (commencing with Section 7000)of Division 3 of the Bunitmssand Promotions Cade) or
• that he is eumpt thamfmm and Bre buts for On allegmd exemption. Any violation of
$8000
Section ]than n any red dont fora permit subjects the.pplkant m e civil penalty of
not mom than fin hundred dollars r. per.
A,�7vt
3 2 622 0 0 2 : S7 V' Number Occupancy Type
❑ I,u OwvrOf Ne PMPray,"myemploy withwa utheirmlecompensadon,
will do thewerie and Ihestructure is nat Intended"onemd forsalc (Sec. 70a4•Business
and Profrsdons Code: The Conuwmrs License Law docs not apply in an owner of
Required Inspections
property who builds or imporm thereon• and who does such work himwlf or through his
Own employees, provided Old such improvements are not intended or offered fonale. If,
however• the building "improvement is within ane yew of completion. the owner•
Wilder will ban the burden of proving that he did not build on improve for purpox of
ffl. owner of pmpen8 . .emanons Cods licensed rnnuano. w
r
covtnsm the project (Sec. Toad• Business and
ct Businessand i Code:) The Canh amrh Lid
.eve taw dao not apply m an awns, ofpropeny who
rty wh Wilds ar Neman, and
who contracts far such pmkcu with a cantrutartU Ikenxd purwam m are Cantrutorb
and p ant M On
�Lkeyyee Lew.
(�f.1
4 in, under
rSeS/..rte ,B@PC ar this m on
Own eeR4D Dam
WORKER'S COs PENSA7lON DECLARATION
ION
1 hereby &from under penalty of perjury ren of the fallowing declarations:
1 ban and will maintain a Certfftesm.f CaMent 10 xlfdvure for Worker's Compere
Ilk
on• An provided for by Section 3700 of the latter Code. far the performance of the
rk for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, u required by Sedan
3700 of the labor COW, for the performance of the work for which this petmil 1, its ad
'
MY WOrkefs CampevadW Ivmance.artier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=It. Andcol be completed if the Permit Is foront hundred dollars (S 100)
or Ices.)
1 certify than in the performance of the work for which this Permit u issued, l shall not
employarys.nin any An c s ores rvbjoctm the Workeu'Compenudon
law( Cal a.
AaL-pplicant
NOTICE TQ APPLICANT: If. after muting hia Ccnifra m of Exmptian, you Mould
beeame subject t. the Workers Compensation previsions of the labor Code, You mesa
forthwith e0mP1Y with such Proviaiou or Nis pe.mit Mall h demand revuk,d.
CONSTRUCTION LENDING AGENCY
I hemhy alarm Nat them is a c.nstacu.n lording age"y for the part.... of
the work for which this Permit W issued (See. 3197, Civ. Q
Lender's Name
Lenders Addoss
I cenify asst I have read this aPplicadon wW sum dtw the &ban informNun ie
cored I agree m Comply with all city and county oNlna ems and aisle laws reledng m
building construction, and hereby authorise mpmxnuuns of this city in enter upon the
ahon-menudgm property for ie pmNan pury0xa
(We) agree to un, indemnify ad kCoP INMAIM the City Of Cupertino against
us,the costsI= andexpenseswhich may in any way acre" sgalnnlsald City
in consequence
nce of
in conxq"nce of the gmnung of this Permit.
U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
�/
SOUR
0NS.11 4'3
"^�J lCN
Re-roofs
Type of Roof
j1V-U: s
'Pat...f App tun on tar �� Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant nom or handl, h,uNov material
u donned by 0te Cupeninm Municipal Code. Chapter 9.13, and the Health and Safety
Code, Section 25532(a)? trvo_
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant ux equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
Itrkt7 hA-onus-itcomaain�an�u u by the Bay Area Air Quality Management
all new materials for inspection.
�defined
❑Yes Q0-
1 ban read the handout materials requimmems under Chapter 6.95 of the Califor.
ria Health h SafolyCodm, Section 25505.25533 aa125534.1 understand Nuifthe building
carnally haw a tenant Net It 4 MY MNMbilitY m notify dw occupant of the
reyui hichmuaMmet 'orwivuan¢ofaCeruOce r a-ICY'
Signature of Applicant Date
O3Dam
owner or ga odaedagc
All roof coverings to be Class "B" or better