06080079 CITY OF CUPERTINO _�.,; ',.� a�,y 'rim t+ ., a
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
' �Cd,':u:a>a:t1m9.
BUILDING ADDRESS: PERMIT NO.06080079
6033 SHADYGROVE D
(R'S NAME: PERMIT ISSUE DATE
CHARLES ROSENBERG & WENDY AN SANITARY NO. CONTROL NO.
PHONE;
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00 LICENSED CONTRACTOR'S DECLARATION Job Description no Ej 1 bunchy affirm that 1 am liv
ced under provisiev of Chxptec 9(Commencing
with Section 7IXMl)of DivWon 3 ofthe Business and Professiuv Codc,and my liceneeu
inmBmreeand erreet REMODEL EXISTING KITCHEN, MASTER BEDROOM & BATH
License Lic.#
cma, REPLACE EXISTING WINDOWS (1) AND SLIDING DOOR
Data
Or
ARCHITECT'S DECLARATION LIKE FOR LIKE
t¢< 1 understand my plans shall W need as public mcnrds
1qU
°0t; Licensed Professional
3 OWNER-BUILDER DECLARATION
pI hcmM1y alBnn Thal 1exempt from the COntrawh Us..taw for IW
1
CC following won.(Section 7031.1.5,Business and Profusuv oCoJc:Any city Or county
Q 29 which qui.a permit to constowL altar,improve,demolish,or repair any structure
�ZY prior of its issuance.also mr,ants the applicant for such permit b fix asigned slalemcnl
,tnklmeeedputianuoneepmvisioMofthe Contractor,u<nee Law laapter9 Sq.Ft. Floor Area Valuation
�~9 (commencing with Section 700M of Division 3 of the Business and pro2uimu Code)or
that he u exempt themfmm and the basis for Ne alleged exem $5000
exemption.Any violation of Y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(115(10).
I,as ownm of fife property or my cmpbym with wage u their sole compewuon,
8193 00
will do the work and Ne structure u notinuended oroRemd forsak(SaA0f4.Business 3 7 Required Inspections
and Professions Code:The Contracmr's License law does not apply m e ns an owner of q P
property who builds m improves themon.and who docs such work himself or through his
Own emplaycu.prodded that such imprommenu are not inumled Or Offered for sale.H.
heilde, .the building Or;mpmmmenn u sol be did one year of completion.the owocr-
builder wIB have Ne WNcn Of proving Nat he did not build or improve for puryoee of
sale.).
❑1,as owner of the property.and exclusively Contracting with Oecused conuanon In
construct the pmFct(Sec.7064.But..and Rafessiem Code:)The Contractures U- (�
cove taw docs not apply to an cwter of Pmpeny who builds or improves daemon,and
who contracts for such projects wit a eonuamr(s)licensed pursuant to the Conuaemes
License Law.
❑1 am exempt u der Bac. .S h p it this n
Dau d
WORKER'S CD dPEN ATION DECLARATION
1 hemby affirm under permlty of perjury One of the following declarations:
❑IhaaandwillmainuionCeruOLamof C...t tself-insomfm Wark'sCompen.
sation,v pmvidud for by Section 3700 of the labor Code,for the performance of this
work for which this permit is isaued.
❑1 have aM will tit inm tit Workeh Compensation Iramr .u mquimd by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Workers Compensation Ivumntt carrier and Policy number art:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed Iran,Permit is foram hundred dollars(SIM)
Or less.)
1 moiry Nat I.the perfarmanee of Ne workfur hWienrth[im spheemu}. ued.I shill not
employ any Person in my manrcas b rso sI K/ Cl VOntui'Compensation
fawa of Califory c I Cl lk�n�
APPlicant
NOTICE TO A o the WoT: L a r making this provisions
of Of Latton on,you u ould
a=
became subject y the Worth Pr Compensation provisions Of the lunar Code-yeti mus
.J O forthwith comply with such pmvu;ov or this permit shall W dcemrd revoked.
'Z CONSTRUCTION LENDING AGENCY
(� Imootyaffrm that f.it.catmvuninn lendingagency ror the perrurmanceur
a > the work fur which this Permit is issued(Scc.3097.Civ.C.)
Lenders Name
IL E
D z (•enders Add.
U O 1 cenify that 1 have rad this application and sista that the above information is
F^ comet.1 agree to comply with all city and county ordinances and sum laws Miming to
'JU Wilding eonsuonann,and hereby authorize mpmacmatives of this city to enter upnn the
CA above-mcmidgm progeny for inspection purpowhich ca.
(We)agree to save,indemnify and keep hesmless the City of Cupertino against
Z incoivutionce rtheg coming ea pensM which may in any way accrue against City
Uz A APPLICANT
of the gumming of NisD WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH////�tt{t....11ll....NON POIM Issued by: Dale
SOURCEREG ON /I J�
1 ( Re-roofs
Signazum of ApplivnUCOnuanor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ju applicant or forum Wilding occupant stam or handle haradous material
az defined by the CuPedino Municipal Cade.Chapter 9.12,and the Health and Safety
k,Section 355720)?
❑Yu ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant vee cquipmentordevices which If a roof is installed without first obtaining an inspection,I agree to remove
Cont h47.2NouS air contaminants as deemed by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
1 have mal the haardous materials mquimments under Cbaptar6.95 of the Califon
nu Health h Safety Cock.Sceuov 25505,25533 and 25534.1 mucuund thxtifthe Wilding
does not cNrendsi:y naa¢nanL Nal it u my resistant lily m noul'Y the Ox pant of the
mqui u which m be met prig[Otissuancc of a Ccrtif
'�� Signature of Applicant Date
04ner or aumori,ed agent D,ta All roof coverings to be Class "B"or better