07120090 CITY OF CUPERTINO '��^ :z� i�'Y os ��'
BUILDING DIVISION PERMIT CONTRACTQR�INFURMATIN
BUIL I�6G MESS: PERMIT ND.
��� MADRID RD TBD — TO BE DETERMINED 07120090
W NER'S NAME: PERMIT ISSUE DATE
ROBERT GEVA 01/31/2008
NONE: SANITARY NO. CONTROL NO.
ARCHITECUPNGINEER: - BUILDING PERMIT INFO
BPLUMB
O O O 0
Sop LICENSED CONTRACTOR'S DECLARATION LS Description
vd u 1 hereby althm WT 1 on li¢ncd under pmvisiom of Chapter 9(commencing O
ing
wed Section 71)(N.Oiviuon3afthe But.and Poral.Code,and my license is REMODEL MASTER BTHRM, 2 ADD.BTHRM,KITCHEN WINDOWS
new in full farce am often.
3�2 License Clan Lie.0
p Dam Centime,
77WW ARCHITECT'S DECLARATION
I undersand my Plans Nall M used as public reenNs
5yU
hG Licensed Professional -
N Oat I am exempt
room
DECLARATION
1 hereby.(Soo that i am exempt Pram Ills Conmctah License law per de
i D o fallowing masa n.(Saito co 13,Business and w.de Professions Cale:Any city stcorny
9� which requires a permit m ennslrmL alcor,impmw,demolish,or repair any awmure
prior in its iuumco.tlwmqui.ateapplicant for such permit m Ble asignW summer
zFp< IhatheI.licensed putwentlothe peovisamsorthe conuscuresLimme Law(Chapmr9 Sq.Ft. F1oorArea [. Valuation
N
3$ (commencing with Seon7000)MDivision 3orthe Business and PrefnssinnrCom)or 0
3 N4 at he axerept therefrom and the basis for the alleged exemption.Any Auladan of
Section 7011.5 by any applicant for a permit subjects the applicant he a civil penalty at Number Occupancy Type
nm mom Nn fe
aw hundred dollsn(SSW), 3 5 6 0 8 0 4 0 .
❑I,u owner of thin papmty,a my wplaym with ages u the4ank campewdion,
will N the work,and the structure 4 rut intended oraQered basak(See.1044,Boni.
and Professions Code:The Coneanmes License Law does ani apply to an owner of Required Inspections
Property who builds orimprowa lhemon,and who doessmhwork himselfor Waugh his
ownemplaye proHde4 at=himprow�uamnotinmWW maBoW forde.IL
huwewr,the building or improvement Is cold within am year of completion,the minor.
builder will have the burden of proving mal M did net Wild or improve for purpose of
mkJ.
❑1.it owner of the propenY,am excdusiwly contracting with licensed conuacmrs to
construct the,pmject(Sec.7044,Business and Profeatlom Code:)Tile Cmu me's LI-
mmm law does mt apply a owner of property who Wilds or improves Thereon.and.
wMeanuacufuramhpmje withacontractar(011wwdputawntmthe Conlrnctoes
License Law.
❑I am exempt oda See. B&P rifte,lots
Gmason
car Data
OR OMPENSATION DECLARATION
i hereby a(Ems under penalty of perjury Was of the fallowing declarWum: -
❑T ham and will maintain a Cenificaseaf Consent la self-inose.fw WwkeraCompen-
scion,u provided far by Section 37M of the War Cade.for the performance of the
wart for which ties permit 4issued.
❑1 have and will maintain Worker's Competition Importance,as required by Section
3700 of the labor Coast,for the Furtherance,of the wart for which this permit is Wood. '
My Workers Compensation Insuom canna and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
This section need ml M completed iftle Permit is foram hundred de0a.(SI W)
or las)
1 modify mel in the perfwmanmlloof TM work for which this Permit 4 Wssued.I shall nut
employ any permn in any mano�dm as m become abject la the Werke.'Comperuadan
Lam of Califomio Dep- /11
Applicant 'V 1
NOTICE TO APPLiCA , ,e r making this CeNRcam of Exemption,you should
become subject m the W 'a Compensation provisions of the lata Code,you most
,QO roMwith comply with such provisions or this Permit Nall be demod mucked.
Z 51CONsTBuc 10N WENDING AGENCY
[••m Ihereby arum that ft.Is.conauuednn hndingagemy for the Perform.of
lYt Jus worse,for which this permit ts issued(See.3097,Civ.C.)
QLanders None ,
D z Wenders Address
f,Q I certify that 1 have read this implication and sum that the show information 4
-Q Ecomm.I agree in comply with all city and county colosseum,and sum ism relating to
building construction,and hereby auNodm opresmuuwa of this city to enter upon Ne
W
above-mendomd property for IwpeNon purpasea
C (We)agree in sew,indemnify and keep hamkas de City of Cupertino against
cn libitum,judgments.cow and expires which may in any my acme against said City _
U 7 in eotregmnco of the grating of this permit. V�
a7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION$,
/ e!� Re-roofs
Signature or AppliundCon Dam -
MATERIALS DISCLOSURE Type of Roof _
WIIl the appllmnt.fMuni WpalCoe.Chapter
w handle heveNuusmasedal -
i as dented by the Cu,.!.Municipal Code.Chapser 9.12.and Jw Hce1N and Safety
w1e,Sweden 15532(.)? I,� All roofs shall be inspected prior to any roofing material being installed.
❑Yes )3No
Will the applicant or fuutture Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cosh hmapous air contamiotsnts a dcfimd by use Bay Arca Air QuWly Management all new materials for inspection.
District?
❑Yes ,®No
I haw reed the howdpu reamriab requirements under Chapter 6.95.r W Caliror.
ilia H.Itb&Safety Cede,Semia 25505,35533 and75534.1undemunddialifM Wilding
Joey not em.ntl haw a mean a u it 4 my ecapoasibility m am" amup t of the
requirementsch 'arm4eumw
maf,ewJncarorcv Signature of Applicant Date
! 9S,
Owner or authoraclageyf All roof coverings to be Class"B"or better