03120027 ECITY OF CUPERTINO '��°"'�r" '•� �'" '� '° `" ""'
BUILDING DIVISION PERMIT ,CONTRACT�QR ,I1V ORMATION
DING ADDRESS: PERMIT NO.
RYMIK DEVELOPMENT CORP 03120027
ER
NAME: PERMIT ISSUE DATE
SANITARY OL NO.
ONE:
I
BUILDING PERMIT INFO
ARHITECnENGINEER: BLDG ELECT PLUMB MECH
0 0 C=
uoo LICENSED CONTRACTOR'S DECLARATION Job Description
C I hacby afRrtn that 1 am 1lcensed under provisions of Chapter 9 mommuating
U wb�satlo yrasky of Division 3af the Business mall Pm(cssiom Code.and my]I--I'
oy LmnL1e.11
rorceaneeffem. REVISIONS (WINDOWS) BATHROOM
j N Z Litton Class
nrq Dau Conlsacmr
W ARCHITECTS DECLARATION
77 1 understand my pi.o.hall be used as public mmrd
�yU
3 u GLicensed Professional
O OWNER-BUILDER DECLARATION
�
im 1 hereby affirm Nn I am exempt from Nulath
e Conlraor's License w for e
O O following moron.(section 7101.5,Business and Peefeuiom Code:My city or county
K$ which uduirts a permit m cromneL slur,improve.dcmtdkch,or repair any momism
HZi prior m its issuance,aLm mquims the applicant for such Permit m fdc a signed statement Valuation
< t,be,ulicensed ptumanmoshe provisions ofWeContractor's License Law(CTapter9 Sq.Ft. Floor Area
sO (commencing with section 7000)of Division Sof the Business and Professions Code)br
that he 4 exempt Therefrom and the buts for the alleged exemption.Any Holation of
Section 7031.5 by any applicant fm a permit subjens the applicant Io a civil penalty of 3 hero 0 Occupancy Type
not more than five hundred dollars(SSW).
I]1,u owner of the pmpeny,m my employm with wages u the'v role cbmPenutian.
will do thewbrU.and the or mute is notinuMed m onnW fursa a(Sec.7W.Business Required Inspections
and professiors Code:The Contrcmts License Law data not apply b an owner b(
property who builds or Improves thereon.end who does such..,it himself or through his
own employees,provided that such improvements are not intended aroRemd forsale.If.
however,the building or improvement is mid within one year of mmplction.On owner
builder will on the burdra.(proving that M did nm build or improve fm purpose of
saic.).
1.as banner of the propeny am esen ively contracting with licensed contractors to
cerm La the es not (Sec.o an Business and ny fessionswho ho Code:)TheCommon'sOc on,Lid f
c law dors not apply le an owner of propeny who builds or improves thereon,and
who contacts for such pmjecu with a contrmmKsl licensed pursuant in the Conuantoh
License Law.
❑I am exempt under sec. .B gs P C(or this moon /
r Dam
ORKER'S CO ON DECLAAATION
thereby
1 hereby affirm under penalty of perjury ane of the following declarations:
❑1 hoe and will maintain a Cenilnm of Cbnscm to suf-insure for Worker's Compcm ,(�
tailors,
as provided fm by Section 37M of the Labor Code,far the performamc of the v (�
work for which this permit is issued.
1 have and will maintain Workeri Compensation Insurance.in inland by Section
3700 of the labor Code.for da pedormmce of the work for which this permit is issued.
My Worker's Compensation Insurance canner and Polity number me:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(LTH stolon need not accomplcied b the Permit is Intone hundtrddollars(g1071)
or less.)
1 certify that in the performanec of the work for which this Permit is issued,l shall am
cmploya tin nvymmmrwuwb omcmbjmtio,MWorkeri C=K=don
Law-of'C Oau
Applicen
N(J.iCE TO APPWCA ,e taking u cn testa of Escmption,you should
b�L Ne subject m the Workers Compensation sovi ic.of the IaMr Code,you must
Z fb,with comply with such provisions or this permit shall the domed mvatrd.
ZO CONSTRUCTION LENDING AGENCY
E I herebya1Rm Out date ire ca len
than ding agency far the pelf u....of
Q$> the.,it fur which Nu permit H issued(See.3032,Civ.C.)
WQ Leader's Name
0.z Lender's Address
t)z I certify Nn ve ons,I haw this application and mNot the above information is
U. (~ cmucL I agree to comply with all city and county ordinances and sum laws relating to
0O bvildingconswnibn,and hereby authorize rtpmxnutives of this city to enter upon the
W above-mentioned pub nny for inspection purposes.
(We)ague m save,indemnify and keep bartnleu the City of Cupertino against
hliabilities.judgments.cosu and expeoses which may in any way..me against said City I
Uz in consequence of the Starting of this permit Date
^' APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON OINT Issued by:
S0 EGULAT15.
// 1 L� (U3 Re-roofs
Omega of pphnHAZA raaor � ��au T of Roof
HAZARDOUS MATERIA DISCLOSURE Type
Will top appliam sir future building occupant amrc or handle hnardous unwind
u deRned by ho CupeAno Municipal Code.Chapter 9.12.and the Health and Safety
c.section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Ycs Y No
Will the applicant or If a roof is installed without first obtaining an inspection,I agree to remove
to.building cecup of use-gaipmcnt or devices whin
emit harardnns air cenuminanu u defined by the Bay Area Air Quality Management all new materials for inspectio .
Dvuin7
0Ycs Nu ♦l
I have mai ties bvaNausmaurials moNnemenu under Chapter 6.95 of the Califor.
nu Health&Sdety Cak,Socmamn5U5,25533 and 25534.1 undersand thatiftM building
does rot currently haw a tenant at I is my responsibility in notify de occupant o the
remm uwhich man be me riot issuance ofa Certifaaa of Occu $IgAureojicant Date
All roof coverings to be Class"B" or better
nen or wtharimd agent D te
rr Daryl Fazekas
Architecture, Structural, Energy
80 W. Main St., Los Gatos CA 95030
L'n I�6--2 I Fax 395 5880 Phone 408 395 9400
RE: 21 O 21 O 4� A Z moi. lvi�2�ul� Date I of c}-
2 IrJc� ti( J/LCv - -1A 0 L Gl2`7 AT "1'7 ��� AT � i9-C, e� �jEArI�
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Thank You, Daryl Fazekas, AIA
v SEp Agcy/T��
DARYL
EKA
N / . C14 g
9rFOF CAko O
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