05080244CITY OF CUPERTINO
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»rRA6,T0it TNF0RMATION P
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
119q VQRKSHTRF CT
DONATELLI CASTILLO BUILDER
rMITNO.05080244
OWNER'S NAME:
PERMIT ISSUE DATE
B:
SANITARY NO. CONTROL NO.
408)287-4886
ARCHITECfIENGINEER:
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATIONo-
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b eSCription
1 thereby affirm Nat I Am licensed under pmvisium of Chapter 9 (commencing
withSadon7O10)ofDiridon3ofde Busiassand PTafcaiuns Codc mdmyliccaais
I. mu cora ane effect. 6' Q u 0-rj
REMODEL HALL BATH a {'
rfil
u¢¢ns Clw�—C
- t
tr
Date L'OnDEC
As shall use DECLARATION
I undorslmJ my plans shall bo used a public sernrda
� 'a '
1 ' "� G
yay' L i`r"
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Conuacsurs License Law far the
follnwing moan. (Salon 7031.5, Business and Professions Code: Any city or county
which requires a Permit N crrtpmcL Arm, Improve, demolish, or repair any suuctum
$28000
Poor In its issuance, Alm requires the applicant for such permit to Bk asigned statement
Sq. Ft. Floor Area
Valuation
that he is licensed pnsum, to the previsions of the Conuamis liana Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business And Professions Code) or
„
that he Is mo mpt therefrom and the basis for the alleged concluded. Any violation of
r U U Occupancy Type
Section 7031,5 by any applicant for a permitsub*m the applicant N a civil penally of
opt mom Nm five hundred dollars ($500).,
m
f1wtlon, _g
❑l.esowarof Nepmpwy.wmyemplaycewithwga Mdeirmkcompe
Ic
and the he Cmuu um's Llcm-Own ma
will do Preference;LAw does .1 Apply an
atW dose oot apply m rt owner
obis Code: The Contamrs
Required Ins 9
9 P„
nd who ries is
enywh who daesauch work hima3forNmugh his
proIAL
Own employ buildaor lmproveuchImpr Improvements are nest martesed for suck. E,
Own employee, provided Neroah ImPmsemw
��n�
t you ofc the owner-
thWilding or improvement 4 cold within one year r mprow, for
will low de burden of proving Wt he did nm build or improve for purpose of
Wilderhowever, the have
Wilder
r •�I' � wOo�l
G/
❑ 1. as owner of the property. Am emotively c.Au dn{ with licensed conuacmn m
construct the pmject (Sec. 7014, Business and Profession Code:) The Camacmis Li.
:'j1
sense Law does oat apply in an owner of property who builds or improves thereon. and
who contra for such pojccm with acontncseNs) licensed pursuant to the Conuacuse.
License Law.
❑lam seem oder BkPC or do. n
_sf✓ 6;Ijy
owns � Dale
ORK PENSATION D LARATION
I hereby affrm under penalty of perjury one of the following declandom:
W,e and will maintain a certificate orconaem m all-ksum fer wonsues compen.
adan, As provided for by Section 3700 of da, Labor Code, for the Performance of the
wort for which this permit is Issued.
❑ I have and will maintain Work es Compensation Insurance, As ropu red by Section
3700 of Ne Labor Code. fa the penformanm of Ne wort for which this permit is Wood.
My Work es Coropejudon Insurance artier and Policy number An,:
carrier: , %xL t6 I1CiMiU�t Policy No.: 0 �, L (.l O S-1 1
CERTIFICATEPI70N FROM WORI.ERS'
COMPENSATION INSURANCE
(This Auction need wtWcmplcwd If the permit Isferone huMred dollars ($10(1)
or leas.)
I certify that in the performance of Ne wort for which this Permit is issued, I Nell nm
'
employ any person in my mmar an As in became subject to tie Wortets' Compensation
Laws of Califomis Date
Applicant
NOTICE TO APPLICANT. If, after mating this Certificate of Esempdon, you should
become subject no Ote Workers Compensation provisions of tM Labor Code, you most
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby aTOrm that Nem is a rnnsuuctinn lending agency for the pmformance of
the uvak for which this permit is Owned (Sec. 7077. Civ. C.)
'
Lenders Name
Lender's Address
I certify that 1 haw; read this application and sues that the above inforum. is
current. I agree to comply with all city and county ordinances and Aute law relating to
building construction, and hereby authorim representatives of this city to enter upon the
above-mentioned pmpeny for Impecilon purposes
-
(Wc) agree to a ndcWdfy and keep harmless the City of Cupertino against
sat espe•-. which may in my sayaceruegainat Wd Citye
�1imffi6cs.JwdL?,.fn%,
ANT ND STA DS AnND ILL COMPLY WITH ALL NON-POINT
Issued by:Date ZGBRE
LA S.
Re-roofs
Type of Roof
a ppliaMContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fulum building acupantatore or handie WasrdM,• material
As dc0ned by de Cupertino Municipal Code, Chapter 9.17, tib the Health and Safety
Cade. section 25532(a)7
J(No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or future building occupant use equipment or devices which
henrdnc air cmuminmuf As re0ned by th¢ Bay Area Air QualityManagemcm
all new materials for inspection.
_Nu
❑Yes
Id❑Yes
1 have mad the hmardms materials requirements underChapter 6.95 of the CalifoncA)N&S
tyS' 3305,23577anJ25331.1undentandNnifthebuilJing
tom nilryhmeat mad ,ithmy pomlhilllyu notify de oceupmt of the
i c wlichmurb metpamma aaa m"Imafampancy.Signature
of Applicant Date
All roof coverings to be Class "B" or better
yeti aged Date