07070200 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � '
— PERMIT NO.
BUILDING ADDRESS:
10612 FLORA VISTA AVE BAY CONSTRUCTION 07070200
PERMIT ISSUE DATE
OWNER'S NAME:
RICK BLESZYNSKI 852 BETI,IN A E 09113/2007
SANITARY NO. CONTROL NO.
NE:
(408) 87':,-1297
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
a o 0 a
p p LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;z with Section 70(10)of Division 3 of the Business and Professions Code,and my license is REV I S I OT l ADD (1) SLIDING DOOR @ BEDROOM
"0 a in full force and effect
License Class Lic•# ORIGINAL # 06040020
t-p Date Contractor
ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
)aU
U.H Licensed Professional
OWNER-BUILDER DECLARATION
j< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p Ofollowing reason.(Section 7031.5,Business and Professio
yns Code:Any city or county
{a. which requires a permit to construct,alter,improve,demolish,or repair any structure
Z r prior m its issuance,also requires the applicant for such permit to file a signed statement Valuation
=a that he is licensed pursuant to the provisions of the Contractor's License Law(Chap=9 c.,q.Ft.Floor Area
t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $0
that he is exempt therefrom and the basis for the alleged exemption.Any violaion of N
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3260803'7
p Number Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
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 sale.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,Bus' and Professions Code:)The Contracwrs LC-
cense Caw does not apply to an o r property who builds or improves thereon.mid.
who contracts for such projects tth conwactor(s)licensed pursuant to the Contractors
License Law.
❑1 am exe pt u Sec ,B&PPC for tis reason—
Owner _IV Date Otis—or-
'S COMPENSATION DECLARATION
I here y afli under penalty of perjury one of the following declarations:
L]I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.) 1
I certify that in the performs cc of the work f w'ch this permit is issued I shall not
employ any person' net so as to subject to the Workers'Conpensadon
Laws a(Califo a.Da
Applicant
NOTICE To :If,of aking this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
E~-h►�-� I hereby alarm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W M Lender's Name
0Z
Lenders Address
U 0 1 certify that I have read this application and state that the above information is
fit, correct.I agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,c and expenses which may in any way accrue against said City
V Z in consequence of the ring of this permit Date
►+ WSOGU
ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
S. —mF 0 Re-roofs
ntractor °"eT e of RDOf
ARDOUS MATERIALS DISCLOSURE Type
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(a)? (� All roofs;;hall be inspected prior to any roofing material being installed.
C]Yes Y`-'No
Will the applicant or future building occupant use equipment or ticrioes which
If a roof i:;installed without first obtaining an inspection,.I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �No
1havereadthehazardou rials requirements under Chapter 6.95oftheCalifar-
nia Health.&Safer Code,Sec 505,25533 and 25534.1 understand thatif the building
does not curre ave a a that it is my responsibility to notify the occupant of the
require ich s ecL ' to issuance of a Certificate o�cu l D . Signature of Applicant Date
All roof coverings to be Class"B"or better
Ow r or horix agent Date