08100004 CITY OF CUPERTINO Y��a,�ia*��7..g..�Kata�,a `n-�ggI°� �"'°
BUILDING DIVISION PERMIT XONTTI t1CT,Q;`Al FQIWATION
rose✓' a.`.m:'�.._., . _
BUIL41V DRESS: PERMIT NO.
L6�1 SOMERSET DR KLOSS DOLORES T TRUSTEE 08100004
R'S NAME: FERMrr ISSUE DATE
KLOSS DOLORES T TRUSTEE 20031 SOMERSET DR 10/01/2008
NE: SANITARY NO. CONTROL NO.
ARCHrTECDENGINEER: BUILDING PERMIT INFO
ADD 160 SQ FT TO MASTER BO O PLUMB Mo
u00 LICENSED CONTRACTOR'S DECLARATION I IOb DOSCiUOn
U 1 hereby of ire Net 1 am licensed under Provisions of Chapter 9(commencing P
mm with S=don7W0)ofDivWon7ofthe Buvnmand Professions Code,arulmyliccnwis
^<s in full fade and eff=L
j Z Licene Class Lic.g
yq Dam Contact,
7W ARCHITECTS DECLARATION
u I eadensnd my plans shell W used ar public¢cords
g Licensed Profcsumal
OWNIL
ER-BUDER DECLARATION
I
.by
aRrm
the,
I em attempt from t e Contractors Lkcnse Law far tW
Z a o following maann.(Section IM 1.5.Busters and Pmfecro
slons Code:Any city or omy
um( which requires a permit m construct.then.improve.demolish.to-pair any armature
_zy prim to its um..also mqul.theappliant far such permit to file.signed sYremoat
Eno
must Is,ulicensed purammtoda,pmviom
isoftheComm
aarlixnmLaw Sq.Ft.Floor Area Valuation
set— (commeming with Section 70D0)of Division 3 of the Bummu,and Prafeuioru Code)o,
tau W is attempt therefrom and the hens fm the alleged eaemps.n Any NOladen of
Section 7m IS by arty applicant fa a Parent'subjects the applicant m a civil PenallY Of APN Number Occupancy Type
not ma-Nan Ew hundred dollars,5500).
0 I,u owner of the property.a my wploym wits wage as deumle compemsdon.
wRmmewak.ndde,hKm- mtmmwdaraBe-dmr,.n(sec.Toa,Burinm Required Inspections
and Professions Cade:The Corto License Law Ems ml apply m an ow."of
9
property who builds.,improms the,ron,and who class such work himulf ar through his
awn employees.pr^Nded that such improwmoas are not intended Or offered fm sale.If,
however,the building or impmwment is mid within am yes of romplctim.the owner-
Wilda will haw the burden of pmving that W did amt build or improv^for purpose of
,ale.).
j"1,as owner of the property..m excliamly mo rMirig with licensed contrast.to
comaua the project(Sec.70as,Businm and Professions Code:)The Commoner's V-
cense law does not apply an an owner of property who builds or imp ows thereon.and
who contracts for such projects with a conoacmr(s)licensed pursuant th the Ondantoes
aces Law.
aempt er Sec .B d:P C r thio maton
WORKER' MPENSATTON DECLARATION/Q
1 hereby affum uncle trashy of perjury oro Of the following dalira0m
baw and will annus a Cenf ammof Cotnenitoself-iuum fmWmkees Compan.
ruin,u provided for by Section 3700 of the Labor Code%fm de perfmromma of the
work for which this permit is iuved.
0 1 haw and will maintain Worker,L'omp anati..Insurance.m nummad by Section
3700 of de labor Cade,for the performance,of the wort for which this permit's issued.
My W.,W.Campemati.O Wsunnee anis and Policy number ere:
Caricr, Palley NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMFENSADON INSURANCE
(Thu sectio road not be completed if the patent is for=hundred dollars($100)
or las)
1 unify that in the Fcrfmmama of the work for which this permit is issued,l shall not
employanypermnto mymwrsah to beect ser jet to the Wmkers'Com cmallan '
Laws of California.Dam
Applicant
1
NOTICE TO APo ith :IG after m s ,i i.Of m em ion.you uhauld
become stubject y it Workers Comp tan pmvisha of tae labtr Calc you must
Oz foMwithcemply with such pavi,iommthu pe,mit,hallIto account rewkccl.
Z O CONSTRUCTION LENDING AGENCY
E-v Ithereby afmm that then u a construction loading agency for the perrormeoce of
C > tha work fm which this permit is Luted(Sec.3077.Civ.Q .
157 � Lenders Name
.7 0 Leaders Addrm
U 0 1 comfy that 1 haw mad this application W ssm and Use show information is
{T. F c.ncct.1 lira m comply with all city and County ONLOarI[er and state law,relating to
0Wilding construction.and hereby authona representatives of this city m enter upon ere
r W above-mentioned property tor impaction purposes
(We)agree to saw,indemnify and kmP harmless;the City or C.,man sg4=
rFi r4'jl liabilities,judgmams.cans and expenses which may in any way amus against mid City
U z APPLLICthis
ANT UN ERSTAND5NO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEg�ULATIp /'6
NS. ' /
/�/ /1 /0< Re-roofs
Signieffreof Applican for
kiA� RDOUS MATERIALS DISCLOSURE see Type of Roof
Will the apPlic(nt or fuwre Wilding aecuPanumrc or lundle hvamom material
ned by de Common Municipal Code.Chapter 9.17,and tae Health and Safety
Section 25532(.)?
[3y. P�N.
All roofs shall be inspected prior to any roofing material being installed.
Will nae apprcan,or mere Wilding.mnpeat ate equipmem Or d vim whim If a roof is installed without first obtaining an inspection,I agree to remove
.sl heramom air canumirons u deGnN by de B.,Area An Quality mmagemem all new materials for inspection.
District?
SYcs No
I has mad the haaardom/ m=dri mWkenenun Chaper6.95.fdeCalifor-
nuHalthStSifely CudaSwd.2550.25533 md25534.I anderssnd thelfthe Wilding
door rot cunetmy haw a noun then it u os hility m notify the mention or the
g
,eairements whKIt x tri., of.Cando: a Signature of Applicant Date
Owner or authamed agcnl / d DamAll roof coverings to be Class'%{."or better