06030020 CITY OF CUPERTINO ' '°"+* R ?ztef 'i,
BUILDING DIVISION PERMIT CCI ''rRA�G`TOR TNF .MA.' 0�,„
BUILDING ADDRESS: PE0.MIT N0.
10574 ORANGE TREE LA
ER'S NAME: PERMIT ISSUE DATE
MATTHEW MATULEWICZ 10574 ORANGETREE LN03/28/2006
PHONE: SANITARY NO. CONTROL NO.
(408) 257-6376
ARCHr1ECUENGINEER: BUILDING PERMIT INFO
CM ELECT1= PLUMB MECH
O O
joo LICENSED CONTRACTOR'S DECLARATION Job Description
idi 1 hereby arman that 1 am licensed under provisions of Chapter 9(commencing
with Section 70(10)of Division 3 of the Business and Professions Cude.m l my lice=h
In fall farm maj (reck REPLACE PATIO COVER W/NEW PATIO COVER-REAR
g? License Class Lk.Y
` Dam Contractor
ARCHITECTS DECLARATION
I understand my plans Nell he used as public me.,&
,tt; Licensed Professional
i3 OWNER-BUILDER DECLARATION
ix I hereby 4M.Net I am exempt from the Contractors Leman Law for the
COO following mason.(section 7031.1.Business and Professions Code:My city or manly $3000
$ftii which requires a permit to conswct,altar,improve,demaluh.m repair any Manure
prior in its issuance.also acquirer the applicant fmsuch Ismail ro file a signed stalernma
E
dust he is licensed purrommut the provisions of the Cortusumne,License Law(Charter 9 Sq.Ft. Floor Area Valuation
z�g (commencing with Section7000)ofDivision 3 ofthe Businessland ProforionCode)or
that he is exempt themfmm and the basis fm the alleged assumption My violation of
Section 70313 by any applicant for a permlt subjects the applicant m a civil penalty of 3 5N um er Occupancy Type
not mom than rive hundred dollars($3001
❑1,set owner of the property,or my employes with wages as their sale compenaldon,
will do she work.and the swnarcisnmamended Or offered for we(Sm.7044,Bubtesa �rr,AA fa Re uiredIns actions
and erty wit obu Cock:Tha Contractors Uceme law den nm apply lf rL oaawer is tpppljjj��\'\\\9\I k�(' ^ q P
man
property who EuilMmimprawa Nemogand who dm sauehwmknimselfor through h6 � '"^ Y
however.the Wilding
or Icon wehimprovemenalarenot lnmMedma@red for wreaf. �%
boildour.the building u Improvement is sold o did ore year or completion.Improve
for the rase of
buildu will have the burden of proNng Nat ha did trot Wild m improve(or purpose of
Cg'1,u Owner of the property,am exclusively contracting with licensed con amore se
construct the pmjca(Sec.7044,Business and Professions Co4c:)The Continuant Li.
come `-�•��
law docs not apply m an owam of property who builds or improves the...and,
who contracts for each projects with a romracmr(s)Iiesmed punmm to the ContnctaM1
License Imalaw.
❑tom ea oder See. .B& Cfm thio moon
OR ERM CO ATO,DEC TION
I hereby Man under penally of perjury one of de following declMtiam:
❑I have and will maintain aceNfinte of consent an selfdnaure par wonfines camper.
sordan,
arworkeracampen-
udon,u 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 Worker's Compensation Insurance.an retrained by Section
37M or the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number me:
Calver: Policy No,:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Thisemacsneed notbecompleted Ifthe puree t la fm ane hundred dollars(SIM)
or lea&)
I curtly that In the performance of to work for whicb thia permit is issued,I shell not
employ any person in any manna as4�b5c me tw Worker'Compensation
Laws of Calif.Ma�Dyc acg2t
. O
Applicant dd��
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you Mould
become subject to the Worker's Compensation provision of the labor Code,you must
.J O forthwith comply with such provisions m m
this permit shall be accrued revoked.
'�
CONSTRUCTION LENDING AGENCY
I•r I hereby dorm that them is construction lending agency,for the performance of
�i de work for which this permit is issued(Sec.3097.Civ,C.) '
W~n. Lon is is Name
r7 z Lenders Address
D O 1 certify call I haus read this applicuion and tum that the above InfomlNon Is
D. E+ cancel.I agree to comply with all city and county ordinances and s n,laws reining m
DU building construction,and hereby authorim mpe,entatirss or this city to ever upon the
W ahovc-mentioned property for inspection purposes.
(We)agrce m save,indemnify and keep harmless tie City of Cupcnim spinal
rrA IlebllWes.judgmcnu,cmuand expenses which may In any way accrue agalesl old Chy
Vin conxgmnce of the grantin of this permit. c
t'+ APPLICANT UNDER Sf DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR GU ATIO
�ers � � Re-roofs
Sigmlurc of AppliesHAZARDO Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the aapplicant Cuperaor future building k.Chapter
more rehandle bualth urs and
u defined by the CupeNno Municipal Code.Chaptar 9.12.and Iw Health and Sdery
Section 255324)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Yu 014
Will too applicant or future wilding occupant me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha erdnm air contaminants u Hoed by Ne Bay Ama All Quality Muallment all new materials for inspection.
District?
0Yus u
I have and the huardmimaedalsrequhemcnuunderChaper6.95ofde Califor.
nu Hca W&SdetyCade.Srctieu 25505.25533 md25534.1 understand Ihnifthe wilding
dm not cu�oily haves thu11um���'''response dI m dry the pant of the
mya'an arehfenlona Ipriprb m f eN tadrae Signature of Applicant Date
OwnJer/ora thadrzdagent �' Dau All roof coverings to be Class nBn or better