05080085 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO,05080085
7763 SQUIREHIT-1, CT
R'S NAME: PERMIT ISSUE DATE
(GREGORY & ISBELLE STACHNIC 08/11/2005
SAMTARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+Cp LICENSED CONTRACTOR'SDECLARATION JobDescri tion
U M
1 rtby affirm that 1 em licevChapter cd under provision of Char 9(commencing p
with Section 7(I ))of Division Sof due Business and Professions Code.and my he,..is
in full force anderreal. INSTALL BUILT IN BBQ/GAS/ELECT.
,nz License Class i^nuc.« -70y'�36
=mac Dam �—/y-oa' ConuaemrC4+z Asa/`e' CONTRACTOR: TOM REILY LANDSCAPE
££ ARCH 4ECI S DECLARATION
f N 1 undersand my plans shall W used as public mounds
5yU
s
Licensed Professional
g
OWNER-BUILDER R DECLARATION
c a o 1 hereby o(Sect thin 11. exempt from the ContractorsCoLicense Law for the
O O fallowing reuon.(Section Lonstru Business and improve.
dimu l h.er Any city or county
5$
which requites a permit nc enmuvee aline ire for such
h permit i fi repair any structure
Out coits iened mrsur requites pft ro0smianf for such Pcrmi'rofile
s.Laedeawmcm
athuhaincingwJPuewanuwWpmviviovoflWComaaaor'snicanselaw(Coc1c)9 Sq.Ft. Floor Area Valua[i$T9500
x�$
dust
(commencing with Section 7000) Divisien3 of me Buxinessand
on.M vi Cadc)or
mat W u tempt mcrt(mm and IW hair for dm allcBed exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom man Bre hundred dollars(SM. 36223021 . 00 P Y YP
I,uownuof Ne MWny.amyemployee=wiNw gnudmirmleeampenvdon,
.ill do the welk.andthxd
enctmtenor
eisno,iaaedofferedforWesec.7a Bni. pm Required actions
and Professions Code:The Contrm es Liave Law does not apply m in owner of q p
properly who buildsmimproves demean.and who doessuch work himselforilmugh his
own cmployas,provided that such improvements art notimmided or offered for We.If. D
however, haw
of
eroving cot hedidnot Xan of completion.me owvP i.;, SID builder will haw me W rden of proving WI he did not Wild or improve for purpose of
rale,. 3
❑1,uowrcrofsbe pec.704,Bexclusively contracting with )TheeCconvmmn I Uy
came La me project(Sec.704n,owner
of and Profusions Code:)The Conmmms, Lig'
cent law does not apply a an owner of progeny who Wilds or improves maroon,
whence Lacb for such projects wimacontacmr(s)liunsed pursuantrothe Conmmtofs I y
License law.
01 am uemptumbers.. .B&Pcimthureaton rue
r Data
WORKERS COMPENSATION DECLARATION
y I hereby affirm under Penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Covent in self-insure for WorimesCompen-
ution,as provided for by Sawn 3700 of the labor Code,for the performance of the
work for which this permit is issued.
El I have and will minloln Worker's Compensation Insurance,as,requited by Section
37W of the labor Code.for the parfomurrce of me wort for which mu Permit is issued.
My WorkInsurance carie
Worker's Compensation Insand Policy number are:
Carrier.(C—vej-eS1— Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tbusection need not W completed ifthe Permit is for one hundred dollars($RR)
or mss.)
I anifv that in the performance of the work for which this Permit is issued,)shall nue
employ any person in any mannerm as to become subject to the Workers Compensation
Laws of califomia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenifiam of Exemption,you should
bomme subject ro the Wodera Compensation provisions of the labor Code,you must
.,O foMwith comply with such provisions or mu permit shall the deemed revoked.
z y CONSTRUCTION LENDING AGENCY
[—� IWreby affirm that then is convection lending agency for me performance of
C the work for which this perroit is issued(Sec.3097.Civ.C.)
Q Undoes Name
Lendels Address
U Q I certify that 1 have read this application and slow mat me show information 0
I, r cosmee 11.to comply with all city and county ordinances and sum laws relating in
p V Wilding convection,end hereby authome mpresenatiws of this city to enter upon use
aWw.menWrodudgm property for inspection puryeses
LEI (We)agree to save,indemnify and keep harmless tW City of Cgxnuao against
y incoisequen consequence
heeo=uand esputy which they In any war'accrue against said City
V,'� in cansegrmrme of the granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREGULATIONS.
�� �—�ytir 'Re-roofs
ignuurt ol'Applicant/Concetor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or future Wilding occupant tore orhandle hauudov material
defined by the Cupertino Municipal Code.Chapter 9.13,aM On Health and Safety
Section 255320)? All roofs shall be inspected nor to an roofing material being❑Yes pout P P Y g g installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamdnv air conlomimmis Is defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes r1(b
1 haw mal the bvardrmxmamials requirement under Chapter6.95 nice Califor-
his Health&SafctyCedc,Sections 25505.35533 and 35534.1 undersand mm ifth,Wilding
does not currently haw a tenant.that it u my responsibility ro nulify me occupant of the
requirements which mugbe=Ipoor soissuanceoraceod'7art�auPmv. Signature ofApplicant Date
/ y-
ncroramhorimcdegcm D,m All roof coverings to be Class"B"or better