08010123 (2) CITY OF CUPERTINO t//tt fir'+p�� p� ,� °t �y`
BUILDING DIVISION PERMIT l.Q;�"�1�C>� Ql�'"I �4�lYJ� SIV -'
BUILDING ADDRESS: PERMIT NO.
22292 REGNART RD VIA BUILDERS INC . 08010123
W NER'S NAME: PERMIT�IIE DATE
MI:K{E & KATHY YATES - 4600 EL CAMINO REAL STE 209 07/22/2008
ONE: SANITARY NO. CONTROL NO.
(650) 948-1077
ARCHITECffENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION O O O
e W m Na 1 hereby sfOrT am Ikeved under provisions of Chapter 9(commencing Job Description
e_= '
in full
iNe
ofl3hrim 3afBusmand
nPrafcstiarudxu
CodednmylicenREVISION, FOUNDATION PIER DETAILS;ORIG 07090124—NO
full forts and effeem
;yy��z L;amc Clns. Lk.N NEW PERMIT.
Fp DateContractor
¢t77Wy ARCHITECTS DECLARATION
WU I uMcma,i my pans"I W mind a public messes
g a.
C Licensed Professional
OWNER-BUILDER DECLARATION
1 hemby,affirm that I am aempt from the Contractors Mecum law for the
following moon.(Section 7031.5,Business and Pafeninns Cale:Any dry or county
which requites a Permit m mnmwt alter,improve,demolish.or repair any saium oo
Prior 0 its issuance,+tote requires Neapplicant for such Permit Is fileasigned saenent
�0
that he is licensed pursuamw Ne provisions of the Comacter's Licerue Law(Chapmr 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of Ne ausincvand Professions Code)at $0
Nm he u exempt therefrom and the barb for the alleged eaanM1.Any violation or
ane Occu
SeNon 7031.5 by any apphiam for a permit mbjeeu the applicant be a civil penalty of Number —Type
no them than five 64 P Y
hundred doll.(LSOo). 36647015
❑I,u awrcr of the prvputy,a mY wployen wkh saga u Nc'v sok eompenotim,
aid dothework•Catone Thu,
conurot NtendrAssoRerWfortatepply to an owner
and Poresd lou Cade:Ire Canuxtor,Uceme 4w aces ret apply lf al revere,is Required Inspections
pmpenywM Wildeeimprovea thama,aMwho anevuchwmk nimssltedthrough his
however.ft uiprovideddistsuch worimprowmmuartnot ear ested cdcmoQered the oak R.
however,Nt have
the orimgavemvng haltl ei i in of year of cavpkda,ate purpose
of
builder will haw Ne burden of proving Nat he did not Wiltl or improve for pugosu of
akJ.
1,as ower of the preperi,w mreluuvely conuaajng with licensed mnocmm an
mm erat Ne pmjen(Sec.70ad.Business and Propositions Coda)The Conctors Ll-
minelaw deco not apply read owner of property,who builds or improves thereon,and
who conuacu for such projeces with a conusecton(s)licensed lsursant be the Conuanofs
Lice.law.
❑me 1ptuncer See ,B&P C for Nis
ms^ reason
T1/ Al— Came 7 Q22M
WORKERS COMPENSATION ION DECLARATION
G e by arms under porosity of perjury am of the following declaraliem:
❑Thaw and will meinaina Cenifiate of Consenttoself-insureforWorter,Compen-
mion,as provided for by Schon 3700 of the labor,Code,for Ne Md...or the
wort for which Nb permit is issued.
❑1 have it will mainuin Workcea Compemadon Insurance,u rtquirM by Section
3700 of the Tatar Code,for the performance,of tie welt for which this permit abound. '
My Worker,Compensation Ins r.artier end policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This mNet rcM mi W co mpked Rth permftb forane bunNee de0ars($100)
or leu)
I ratify that in Ne,performance of the work for which this Permit is leaned.l dull not
employ any person in any manmrsuurebecome subject to the Wortar Comp emou
Laws or California.Date
Applicants Asvtw pn1
NOTICE TO APPLICANT-It.after making this Cenir au of Exemption,you should
become subject b the WdAefs Compensation provisions of the Laborene-Coyou mus
.J O forthwith comply with such provisions or this permit shall W deemed revoked.
z CONSfRUCIONLENDINGAGENCY .
(•-'r I hereby affirm Wt there;,a construction lending agency for de performance of
C> tha work for whim this ror,Is issued(Sec.3097.Civ,C.)
4 0 Lenders Name .
z Lenders Address
U O 1 country that 1 haw read this application and sate that the show information Is
U, comma I agee In comply with all city and County orelinm,aM sae laws muting to
O building construction,aM hereby aduchae represenutiws or this city to enter upon Ne
+hove-mentiomd property for impemion purposes
F y (We,)agree N ave,indemnify and lcep harmless the City of Cupertino against
H lisbilitie,jaagmenu.emu and apenoa which may in any way+roue a gal.said City
U 2 in canwquence Ne,granting of Nu permit
APPLICANT DERSTANDS AND WILL LY WITH ALL NON-POINT Issued by: Date
SOURCE RE L�A�TION. / I
LC7 b< r Re-roofs
Sgmature OAppliesumnC.Ituracto, / Date
/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W!B the CuCantmfMuni Municipal
Co e,Chantateessanddk Health anmaterial �-
u deBSec by tie Cupertino Municipal Code.Chapter 9.13.and tW Ha1N and Safety
W,
Section 25532(.)l All roofs shall be inspected prior to any roofing material being installed.
❑Yen v jNo
Will the applicant or future Wilding aavPant usa equipment or devim which If a roof is installed without first obtaining an inspection,I agree to remove
omit hmardous air cmaminanuas defined by the Bay Ama Air Quality Management all new materials for inspection.
Dumcal
(]Ya WN.
1 have mW the Wm =mawddamquhcmemuund,,Cl ,P 695ofNeCalifor-
oust N&Sdmy Cask Savor 3530.5,35533&,125534.I udmuM NnifNe Wilding
dam rot currently hew a enmt that a b in mibility in maty Ne oaupant nr Ne,
requirt�ylw�mh�muss pee 'or ran era certirese or Ocmpmcy. Signature of Applicant Date
agcn 7 ow All roof coverings to be Class'A"or better
Owned or authorized agcm / We� g