08050061CITY OF CUPERTINO
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BUILDING DIVISION PERMIT,CIAV
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BUILIN A DRESS:
PERMIT NO.
T1V9 STAFFORD DR
LOUIS J. PIRNIK GENERAL
08050061
HER'S NAME:
CONT tCiuxPERMrr
ISSUE DATE
NEBENZAHL ELLIOTT AND LINDA A
6884 HAMPTON DR
05/23/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)268-3800
ARCH=fENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSEDCONTRACIOR'S DECLARATION
Chapor 9
lob Description
p
I hereby affirm Was I w limed under pmvidom of (wmmencing
with Scefm70W)of DiA6on3of the Betin=and Professions Code. mdmyliccnx is
ADD CLST TO.MSTRBDRM REPLC SNK IN EXTNG BTHRM
fame and cR¢L—I Z 7
Lifcol Lie..
LOUIS J PIRNIK RENEWD "BUS LIC 5/6/8
Dem Co. 1
ARCHITECT S DECLARATION
I understand my plans Wit W used is public mmrd
'
Licensed Pmfearional
OWNER -BUILDER DECLARATION
I hereby aRrm that I am mempt from We Canlranors License law for We
following mann. (Section 703 1.5, Business and Rofesticm Code: Any ply or county
which requlrea a permit to conwuct after. improve, demul'M, or repair any su enure
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! prim to its issuance. also mquima the applicant for such Permit o file a signed comment
that W it licensed to We of We Connectors U..Lou (ChaPmr9
Sq. Ft. Floor Area
Valuation
pummns provisions
(commencing with Sectio 70(10) of Division 3 of We Business and Profemiom Grdc) or
$20000
I Nat he is camps tWm(rom and Oe basis for We alleged eamption. Any violation of
Section 703M by amy applicant fees permit subjects the applicant b a pvil Penalty ofNumber
OGGU
Occupancy Type
not mom Nan fin hundred dollen (M),
3 6 211019 .'V(
❑ 1, a ownts of the papery, m my rmployem with wage m theb mle mmpemadon,
willda We wonkand thenumom is not minded or offered formic (Sm. 704 f, Business
Required Inspections
and Prehish ns Code The Canmmors License Law don ret apply to an owner of
q P
Property who build m im prove themun, and whn docs such work himm1f or through his
awn employ., provided timsneh imprown ou sm not intended oroRened for oak, IL
hwe ar, We building or Improverovmt issold within one yeti ofcmopkdomNeowner-
builder will new the burden of Proving Nm W did not build or improv for purpue of
sale.).
Cl 1, es owner of We property. am exeluSwly contrasdin6 with licensed rontracore in
en num We pojax (Sec. 7041. Business aM Rofcssiom Code:) TW Cmuwwes u.
cc oea not apply o an war of property who Wilds or improve Merton. and
wWrace u m pini I autocturHNiarucdPormnnsn7Nc
Limmms
�-
ucmpt undo Sec d^P is resson
ncr Dam
WORKER'S COMPENSATION DECLARATION
I hereby aRmt under penalty of perjury one of dm following decimation
❑ 1 My and will mainuin a Cenifinm of Convent to self-imurt fa Workers
i for 3700 of de labor Cod. for IW pcAarmance of Ne
workr whit ison
wart for which Nis permit is Tana)
thismi is
❑ I haw and will maintain Workers Compe rsa0on h surmce, as e pored by Section
37W ofthe laixr Code, for the perfarmams ofthe wink for which this permit is issud.
MY Warka/ess c�me,/s�ati n Inaurmce artier ud Policy numb'efr�am: -->
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Cartier. 7Tt'LLY FU N f PolicyNo.: 4-L S�
CERTIFlCATE OF EMPION FROM WORKERS'
COMPENSATION INSURANCE
(Thuxction reed ret W camplewd if We permit is forum hundred Oil= ($109)
or kis)
1 certify N a for which this Permit is issued. I shall not
enmrmarbbcta SabJaeLla WarIT`3 Campenaadan
aGlic D m
fomm'a
A )
NOTICE TO
NOTICE APPLICANT. IL a0or making this CcrtiEeae a ou should
WOD
become subjcm tun Workers
b Compeor provision Of Labor Code,
M
fawiN cpmP1Y with such Previsions or Nu permit all W dmrmd rented.
this
is sh de
CONSTRUCTION LENDING AGENCY
thereby affirm Nat Nem is a construction lending agency for the Performance of
We work for which this Permit I, issued (Sec. 3097, Civ. C.)
Lendeh Name
.mites Address
I mortify Nat I haw read this applicamion and sane this the aWw janmudun is
corwa L I agree b comply with all ply and county Odl. and sate laws mining to
Wilding construction, and hereby authonm representatives of Nis city to cater upon We
aWw-mentioned property for im xacuon pbymes
(we) ju agree b cost, indemnity aid keep hayiin m de City of Cupertino against
awhich may in any wyaarm against said City
incoidu,Judgmcnu, swung
in comequeme oftW Eantine of this permit.
this
PPLICA
APPLICANT U DERSfAND$. WILL 00 LY WI ALL NON -POINT
LL
Issued by: Date 2 Z'
SOU U ONS.
Re -roofs
' f
Sm umafA I UCanuxtor/G—
Date
HAZARDOB MATERIALS DISCLOSURE
Type of Roof
Will We applimnt m Futuro Wilding mcupant sore orlwdle harudom natural
ss defined by We Cupertino Municipal Cade, Chapter 9.12, and the Health and Safmy
. ection0y. 25532(,)7 �,>ra
❑Ye ®1
All roofs shall be.inspected prior to any roofing material being installed.
C equiP
W II the, applicant or future occupies um mem or deviw which
If a roof is installed without first obtainingan inspection, I agree to remove
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emit havadom it miumio nu u defined by the Bay Arta Air Quality Management
all new materials for inspection.
Di nct7
❑Yu Nu
I haw mad NehvadwsmamriaHrequiremcnuumkrCWpmrh.95 of Ne Califor-
niaHcahhk Safety C?d., Sm. .om25505,25533 334.IuMcreand NaifNe Wilding
Jets ret Immo YE9v a moms.dyIm t u
'Nlimy b ratify de occupant of N7e
mgeirementsw i,:Kmuv be mm pnaFof. Cad am aramp"a"
Signature of Applicant Date
All roof coverings to be Class'W' or better
Owner an ant >ca.gent Dow