06040020 CITY OF CUPEsRTINO 'M0
uaDAI`"
V'
INc DIVISION PERMIT FOR
BUILDING ADDRESS: PERMITNO.06040020
10612 FLORA VISTA
OWNER'S NAME: PERMIT ISSUE DATE
BLESZYNSKI, RICK
IS: SANITARY NO. CONTROL NO.
ARCHIBECTIENOINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MEC14 O
Op LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing
with Sodom 70010 OfOivislon 3O the Businm and Prolamin-Code.sed my lichee is
i „ In fall fame,and effect SFDWL-2843 ' , GARAGE. 490 '
i Z License Class Le.g
i 0 Dau COnttacto,
ARCHRECPSDECLARATION
i i underhand my plans shall he used as public.,arm
i U
:It; Lironsed Profeasionel
OatIam amps From
mDECLARATION
2 I hereby M.that I em eumPm from Ne Contractor's Lheenm law for the ,
:00 fallowing mamn.(Section 7051.5,Business and Profession Cade:My city or..my
jS 9 which requires a permit to mnnran,Ater,Impmw,dcmolen,or repair my structure $637076
-Z- pd.,b its issuance,also requites the applicant formals permit W rile a signed sutemem
i�g that he k licanded purhsant to lir provisions of the COntracmrs license Law(Chapter 9 Sq.Ft. Floor Area Valuation
'S $ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)ter
that W is exempt IMmfrom and the basis for the alleged inscription.My vl0eti0n of
Section 7031.5 by my applicant far a permit ubjav the applicant los civil penalty of jkPN lwwier U,U, Occupancy Type
not mart d m five bmtdmd dollars(5300).
❑1,u owner of the property,m my employers alth wage u Ju'v ark compensaJon,
will do Newark and thesuactua u net intended moneyed foraak(Sm.7044•Bunness Required Inspections
and Prefesslons Cade:The Connect License Law tlms rot apply M m Owner of q p
property who bu iids sir im prove theseon.and who does such work himself or through his
own employees,provided that each Impro mmeau are rot intended Oronered for sale.If.
however,the building m improvement Is mid withinane year of compledon,the owner-
builder will have the burden of proving that M did Out Wild or Improve for purpose of
sale.).
❑1.as Owner of the pmpeny,am exclusively combating with liceneed contractors m
wmtrum the pmjm(Sec.7044.Business and Profession Code:)The Costracmrs U.
cause Law tiara rot apply m an Oester of property who builds or improve Duman.and,
who comment for such projects with a conumods)Seemed pursuant W the Commen s
Lim.law.
01ere der See r/� .B&PC r"do.roams
OwnerCADau Gla '
P1
WORKER' PEN
OMSATION DECLARATION
I hereby affirm under penalty of perjury am of the foluwing dalemOOne:
haw and will mdntsin•Car asses of CPMent to self-insidefar Weakn'sCooper.
satlon,u Provided for by Section 37M of the labor Cade,for the perfurmmm of the
.,it for which this permit is issued.
❑1 have and will mainuu Worker's Compensation lambasted,as acquired by Semon
37M of the lab"Code,far The performance of the work far which this parent is blued.
My Workers Compensation Insurance aria and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thtssecdm reed Out be completed If the petrmit is foram hundred Eagan(SIM)
or leas)
1 certify that in the performance of the work for which this permit is Wood,I shall not
emplityr.' 11 Eon in any mmmr m a w because subject to the Woftam'Compensation
Laws of OalhfasfiipOatc
NOTICn ' IST 1
NOTICE TO PLi a Worr If, ter making this Certificate of Exemption.riad you should
become subject y thew en ro Compewtiin provisions of au labor Code,you mut
.,O forthwith comply with such prnvisiOnu"thnt permit ihallMdcemed revoked.
z CONSTRUCTION LENDING AGENCY
r_ I hcrchyaRm that there ea constructs.lending agency far the perfurommeed
C >' the wort for which that permit is ivmd(Sec.309'1,Civ.C.)
[Ll Q lenders Name
]Z Lenders Addis
U 0 1 mortify dial I hats read this appli"um and suss that the shove infom adun is
D.i~ correct.1 agme to comply with all city and county ordinances and sum Saws mlating to
DU building construction.and hereby authotire representatives of this city to cnur upon Inc
Uabove-mentioned property far inspection purposes
(We)agree to saw,indemnify and kap harmless the City of Cuper n against
mF—t raA IiabiliJes,judgments.costs and expenses which may in my way accrue aSamt mid City
UZ, in consume=of Jse granting of this permit.
�^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO�URCgCULA710N5.
` ,1�`b�1 SUl7 V�-Is '.i- '71V L0 6 Re-roofs
Sig roof ApplicamOoorilasular Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant orfuture Nllding ocoupant mm"Mndle harallous material
M derine0 by the Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety
Cade.Section 37333(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building common is equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t harardnm air rontaminents u denned by Use Bay Area Air Quality Management all new materials for inspection.
DisldctT
❑Yes [:1 No
1 have read the hreardmms manuals requirements under Chapter 6.95 of the Califor.
nia Health&Safety Cade.Sodom 35505,23333 and 15534.1 understand tau ifthe building
does amt currently hew a tenm4 Nat It u my mspomibllity m notify the rc wt of the
req wo:hmust beMCI prior uiuummofaCcNOuteof cu°a Signature of Applicant Date
�/U�f l•
Owner or authomad age a
Dau All roof coverings to be Class"B" or better
'