06060177 CITY OFCUPERTINO .yrw +� � tra,�°� "
BUILDING DIVISION PERMIT .�` QNTRA�Q*1NF0RMATION
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BUILDING ADDRESS: PERMIT N00 6 0 6 017 7
10612 FLORA VISTA AVE
EWS NAME: PERMIT ISSUE DATE
RICK BLESZYNSKI0.8/03/2006
NE: SANITARY NO. CONTROL NO.
ARCHITECVENGINEFR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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loo LICENSED CONRACrOWS DECLARATION - Job Description
m 1 hereby affirm Nat 1 am liamed under provisions of LTapmcr 9(ammcncing
>; wthncortoa"f(efDivision xofthe Budnevand Prrassiomt. Code.aMmylice�ia DEMOLISH ONE STORY HOUSE.
,n E License Claw Lte.N 6141 Y�
i Dae CS 1ECL�� b
ARCHITECTS DECI.,RATAM'U/7 Gf/„9 �vQJ� GO
I I unticrsunJ my plans shall W used as public records
lyU
Q Licensed Professional
y OWNER-BUILDER mDECLARATION
00 I hereby maso .(SSero that 1 am exempt from the Canino Co License Law far the
p O following mason.(Baden 7fD IA,Business and improve,
dem ns Calc:Ana city of county
which mquima a permit m crams the alta.W prow,demolish.or mpur any aernam $8000
-zry^ poor to its issuance,
ensedpalea mquiru provisions
inion of for such permit m Ekasiaw(Ch(Chapter
isnheislic&wit pursuant m lineeproviviou of de,Conuisawa Licenselaw(Chaptm9 Sq.Ft.Floor Area Valuation
$ (h:he
xempt Section 1000).f Division ofthecednmorpda.Myo cmi,an of
Nu io u exempt b therefrom and the buts far the dWged eamant to Any Walaiun of
Section 7031.3 by any r dicent for a permit objects Ne applicant •Civil penally of Occupancy Type
not mart Nen Rw hundred dollars(5300).
❑1.u owmu oldie property,army emploacss with wages u Nem sole rompemdon,
will not the wary,and the smmnen is rot Intended or offered fade(SM.7O3s,Budxu Required Inspections
and Pmfeamau Cade:The Cormas mrs Licences,Lew dawu
Class oat apply Wan e of q P
propcny who bolids or i mproes thereon,and whe does such worthimself or through his
howempmy building
Provided pr webimprowmeatsart not ear ded ofemo@red!or molts If.
however,Nc WildingarimProwment4and within oroyear ofim,ram Wa,Ncpnom r.
of
builder will have the Wrden of pmWng that he did wt Wild m improve fa Purpose a(
au,). /
❑L as owner of ct property.704 am Business
W uncreProfen 0ng with licensed ronbamon W
came La d Project apply
o an B.of rote property
who
Cade:)The Conua-'mh U.
cane Taw dos not apply c an owner of property who WIW rs W pmvn Norton,and,
who License
L.contracts fur such projects with a eanuumoKs)11¢nad pursuant m Ne Convectors Q
Leve Law.
❑lam exempt undo See .B$PCfor this moon \p
Dam
WORKERS COMPENSATION DECLARATION
I hereby shim under penury of perjury aro of Ne fallowing declmtiau:
❑I ham and will maintain a Certificate of Cament W self-Insum far Worker sCompen-
sidon,as Provided for by Section 3700 of the Labor Code,far ttw perfomonca of the
work for which this Permit is issued
❑I hoe and will mdnuu Worker's Compensation Insurance,u required by Section
37M of NO labor Code,for the Krfamwnce of Ne were,forwbich this pmmh is issued.
My Workers Compeua�Id,o'n��lu�fum�e.artier and Policy numb r art:
Carder. 4��Sa�( C Policy No.:1�
CERTI TE OFEXEMPr1ON FROM WORKERS'
COMPENSATION INSURANCE
(ITU action Lexi at hecumplemd if de permit Is farm hundred anion($100)
or leas)
I«Nfy Nat in dW Perfoemaece W the work far which Nis Permit is handed.I shall not
employ any person in hay manoran u m become wbjen to tk Workers'Compeaudon
Lave of Caiifomla Date
Applicant
NO710E TO APPLICANT:If,after making aids CeniRutc of Ea repdon.you sheuW
become subject m the Workces Co npcoudon provisions of site Ichor Code,you mum
., foMwidi comply with each proor Nu permit it thdremovedl removed revoked.
zO� CONSTRUCTION LENDING AGENCY
F" I hemby afnrm that them is a construction leading agency for the performance of
E> the work for which this permit is issued(Sec.5097,Civ.C.)
W E Landers Name
Z Lenders Adders
U Q 1 certify that 1 have mad this application W sum Nm tk show information is
IL P cameo.I agree to comply with all city and county Ordinances and sou lam felting W
DU building conwuction,and hereby authodmmpmsenutias of Nis city to trio,upon the
W alwvamcmiunW Properly far inspection Purpotes.
W (We)agree to sew,indtmni(y and kap harmless the City o(Cuperium against
i—� W liabilides,judgmanu,toxo and aspens which may in hay my acerae againstaid City
in cootuonce of the U Z APPLLIICANf UNDERSTAmantiNDS ANDo(thWILLWILL.COMPLY WITH ALL NON-POINT Issued by: Date F-y(/
SOURCE REGULATIONS,
0�.�nlf9 6 Re-roofs
u 2--=
Signureo pPlicanmtac,Our� Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will de opPlkant or forum building ampant ern or COMIC hovrdou material
as de0ned by the Cupertino M1Pat Code,Chapmr 9.1x.and the Health and Safety
.S❑ection xss5x(aI7 All roofs shall be inspected prior to any roofing material being installed.
Yea
von Ne,ppI, t or future building occupant um equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
emit Iwyardau al,ameminanu�as defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict? tr-1-.WIC,
❑Yes u
I haw mol the hmfdnus materials requirements under Chaper 6.95 of the caiifor-
ni.Waith&Safety Code,Secdaux5-%5,25533 aril 25534.1 understand Na ifde building
dao not cumcntly haw a mnanc dot It Is my responsibility to notify the occupant of Ne
rtyuimmmrts which mum bo�do-r W^issuance of a tnfieae arOcapeaey Signature of Applicant Date
r =307 7 All roof coverings to be Class 'B"or better
Owner or wthodreda.;,at Dam'