06080076CITY OF CUPERTINO �a,��ra+
BUILDING DIVISION PE Ryyyly
f
BUILDING ADDRESS:
LOUIS J. PIRNIK
PERMIT NO. 06080076
20665 NANCY rT
R'S NAME:
PERMIT ISSUE DATE
MARJORIE GILBERT
6884 HAMPTON
. -.ONE:SANITARY
NO. CONTROL NO.
(408)268-3800
ARCHITECT7ENGINEER:BUILDING
PERMIT INFO
'BLDG
ELECT PLUMB MECH
l� E 0 I�
LICENSED CONTRACT'OR'S DECLARATION
Job Description
bereby 4ffl m Net 1 am licensed under previsions of Chapter 9 (commencing
with Section 70110) of Division 3 of the Businw and Prorcaium Code. and my license is
in fa 11 farce and effect.
BATHROOM REMODEL WITH SHOWER ADDITION - NON STR
_
Lice w Lie.-lranor
Dau Coachmen,
ATION
I understand my pWu shall be used as public records
Licensed Pmfcaianal
OWNER -BUILDER DECLARATION
we
I hereby .from that I am exempt form the Conuxtoes Ucmw Law for the
fallowing mason. (Section 7131.5, Busiws and Profeesitsm Code: Any city or county
demolish,
7�
$13000
which requires a permit to comene, alt income. er repair any structure
prior In lex Issuance, also inquires; the applicant for such permit to Ole a signed su ement
Contractors Lhxmc Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he u licensed pursuatn to the provisiam of the
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
that he is excerpt therefrom and Ne basis for the alleged essmpdao. My violation of
3 WgbVr-UOccupancy
Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
oat name Nan five hundred dollars ($500).
❑ L u owner of dice Fop", or my employ= with warm as Their auleeommwdon,
Required Inspections
P
Buair
veld da the Won;; Comi lscur s
of
Livens Law does
Professions; Code: The Conxanors License Law d= not apply m Mn owner of
and Co - The apply Win
q
property who b, andmum atiltworkbi Uwugb his
arty
offean
prvmedthwa him dW m°Bcrtd fmaak.IL
own employ=, proWded dial xteb impsysemenu ase r
elle xJr ori m
bowder ills ballding ar e yeacr
Y sodthat forn. dx pose
improve of
builder w10 have the burden of previn& Out he did nal dilW m Improve fm purpose of
den o gravid he
ak.).
I, as owner of the property. w exclusively contracting with licensed cenaatms to
commas the project (Sec. 7040. Business and Professlom Cade:) The Cnawesars U.
coma law d= not apply to an owner of property who builds or Impmwu Ihareun, and
who connacu for Much projects with a rnntsacws(s) licensed pam uant in the Canuannes
License Law.
❑ l serexempt under See .B A P C far this reason
rDECLARDale
WORKER'S COMPENSATION ATION
1 hereby aDim under penalty of perjury one of the following declw0om:
❑ I has and will maintain a Cenifscese of Cowm re self-MumfmWerkersCompcn-
union, an provided for by Section 3700 of the labor Code. for the performance of the
work for which this permit is issued.
-
❑ 1 have and will maintain Workers Compewtion Insurance, as required by Section
3700 of the lather Code. for the performance of the work for which cru pe.i, cleaned
'
My WorkerssC/Co��mpesa�tion Imuran¢ carrier and Policy number a rt:
_/
Cartier. NS, Tis Policy No.: _�
C CATEIF OF EXEMPTION FRO WO KERS'
COMPENSATION INSURANCE
(Thu section recd not bccompleted if tle permit Is (orone hundred dollar ($100)
or Lasa)
I certify the In the performance of the work for which this permit is mood. I shall not
,
employ anypermn in my manner an as an become subject to die Worken' Compensation
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
biome subject m the Workers Cmnpewtion provisions of the labor Code, you mux
' forthwith comply with such provisions m this permit Nsll he deemed reveled.
CONSnWCcIONLENDING AOENCY
1 hereby thi Wt there u a construction lending agc=y (m do performance of
(Se.0
' the work for which this permit u iastd (Sec. 3097. Clv. C.)
which
lenders Name
Lenders Adn,...
j 1 certify that I hast =d this application end suss shat the show information is
' correct. I agree to comply with all city and county ordinulcp and sate lawn rolming to
huilding convection, and hereby authorive mpmsentativn of this city 10 enter upon the
.hove-mend.und propuny for inspection puspoxs.
(We) agree to ave, indemnity and keep harmleas the City of Cupertino again
j Iiebilides,judgments, costa and expema which may in any way accmc against said City
in conxqueme of the of this permit.
F -r/"
g.do&
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date - e e�
S RCE EGULATIO
Re -roofs
Signuu of Appli Dau
H DOLS MATERIALSDISCLOSURE
Type of Roof
Will the applicant teme building oavpat awe er handle huudo smalmul
dented by the Commuin° Municipal Code. Chapter 9.11, and the Health and Safety
n. Senian 25537(a)?
All roofs shall be inspected prior to any roofing material being installed.
Ya
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or Futuro building occupant cite equipment or dcvi= which
emit hanNnm air contaminants a de0ncd by Ne Bay Arta Air Quality Management
all new materials for inspection.
District?
❑Yes r]Wu
1 have mW the bvsNrwss maurials requirements undcfChapmrG95 of the Califor-
1 nix HcalthkSafetyCode,ScWOM255B5,15533md75534.1undenwWthmird Wilding
d= not currently haw s tenent, the it u my =ponsihility m notify the occupant of the
rtyulne. us which no me u of Good .fic.aPutey.
Signature of Applicant Date
All roof coverings to be Class "B" or better
owne r.atnnrse cal Da