06060181 CITY OF CU"ERTINO �T h�'
BUILDING Di,]SION
PERMIT
BUILDING ADDRESS: D INYARI INCORPORATED PERMIT No.O 6 0 6 0181
10475 BANDLEY DR
OWNER'S NAME: PERMIT ISSUE DATE
TIM WAGEMAN 500 PNELAN .AVE 06Z20/2006
ONE: SANITARY NO. CONTROL NO.
(408) 289-5400
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Ll O p LICENSED CONTRACTOR'S DECLARATION
U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
t Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
"'M CAo in full force and � ;✓5� REMOVE CAPSHEE & OVERLAY FIRE A RATING INSULATI
DaenscCl sem" C3 Co.1f WITH TPO 60 MIL MEMBRANE
F„� Date Contractor
„t ARCHITECTS DECLARATION
I a< 1 understand my plans shall be used as public records
�yU
wy Licensed Professional
n
0,
OWNER-BUILDER DECLARATION
1 hereby atTirm that 1 am exempt from the Contractor's License Law for the
i a O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct.alter,improve,demolish,or repair any structure
y Z y prior tit its issuance,also requires the applicant for such permit to file a signed statement
F_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valu$t"7 2 0
nt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(5500). 33 3111 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does trot apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sate.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License law.
❑1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
L I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the i
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. CAI-1 F'• 101• Co Policy No.:4"O 7S 5Z10)e02
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
ai•�
the work for which this permit is issued(Sec.3097,Civ.C.)
Wn.0 Lender's Name
.7Lender's Address
U C) I certify that I have read this application and state that the above information is
LL"" correcL I agree to comply with all city and county ordinances and state laws relating to
CU building consuuction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rFt liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Dare T e Of Roof
HAZARDOUS MATERIALS DISCLOSURE yp
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes j<No
Will a roof is installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes flu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safcty Codc,Sections 25505,25533 and 25534.1 understand that if Ibe building
d rcurrently have a"aro.that it is my responsibility to notify the occupant of the
re\uirc ots m be me prior to issuance of a Ccrtif to of oc ancy Signature of Applicant Date
Oty'ncr ora tharixcd agcn �, Datc All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
-'UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: TM WPC GM A tJr,.� PHONE #4C 9 -
GENERAL CONTRACTOR: D1lJ YPA / L FAX # 4-0 g c(-74 RC1 Go- c
I am not using any subcontractors: y
Signature Date
Please check applicable subcontractors and complete the following information:
21 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Own r/Contractor-Signature Date
, _
WUoD J 1
CITY OF CUPERTINO
� 4
CUP,ERTINO PERMIT APPLICATION FORM
APN# �2( Date:III 1 � -2-0 - top(,x:9
Building Address: t 047 S B ArJ_PLG y -Die— CA GtSO 14
Owner's Name: Phone #:
Y l M 40$' 0140 - ff D O O
Contractor: License #: SC G �G4-
Contact: Cupertino Business License #:
Type of Roof Covering:
Existing;, Proposed:
Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify) IG
Number of existing coverings Z 0'Provide I.C.B.O.Report# VL — 57 5
,W1,To be Removed Provide Mfgr.Installation Specs. EA2L51
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description: ►�f
P4a'l0JP_r cpegRia uVT �- ��s�,211� CRs � �c/a,—��.3�1 0 60 ra�U tnMIQ
Residential ❑ Commercial
Fire Zone: Yes ❑ No ®' Confirmed with Planning Det. if
there are an restrictions: LJ
Cost of Project: .� Type of Construction: Occupancy group:
- 3
Qty. if
Applicale Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING