08110005 CITY OF CUPERTINO
�,fCON
C kkbt ( , "ORMATTOM
BUILDING DIVISION PE NUT T' "01--l'
BUILDING ADDRESS: PERMIT NO.
ul
21890 DOS PALOS CT S. EA. CONSTRUCTTON ORII0005
OWNERS NAME: PERMIT ISSUE DATE
BYRNE NIQUARI C� AND 1943 Q-TA.PRELL SEP I n Ll C LnnnO
ONE:
� CONTROL NO.
ONE: s*KffAi
(650) 802-9585
ARCHITECT/lENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
seep LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thus I am flumassad under ProviSmas Of Chapter 9(Commencing Job Description
a wich Section 7000)of Division 3 of the Busimar and Professmics Code.and my ficems is
in full chat Sand Iffect. A ADD 188SQ TO BK OF HSE(FAM RM)&PORCH(54SQ) ;RMDL
:t 11 3i License am Lac.
Dow Commete,S.6.A
&g i
iEqa I ARCHITECTS DECLARATION
I mudersumd my plans mail Im used as Public reconds 189SQ, 1BTH(40SQ) &OTHR(54SQ)
Dillu
I S.
�J� Licensed Padfasi...I
A0 1 OWNER-BUILDER DECLARATION
z I hemby Same that I am attempt from the contraclot'A License Law for the
C 0 following nation.(Section 7W 1.5.Business and Professions Codc:Any CRY or County
.V which requires a permit to construct,cher.Improve.demolish,or repair any mucture
T
prior in its issuance.also requires the applicant for well permit in file a signed andement
that he is licensed pursuant to On provisions of Oc Contractor's Lemme Law(Chapter 9 Sq. Ft. Floor Area Valuation
YFQ (commencing with Section 7")of Division 3 of the Business and ftlastions Codc)or
on,he is exempt Otinform and the basis for the Singed!comaption.Any violation of $89641
Section 7031.5 by any applicant far a Small subiccu On applicant W 2 Civil PermllY Of APN Number Occupancy Type
set annion,Om five hundred dollars(M)
032645019 . 0 0
1,as ower of the property,ar my employees with wages u thev Sale compewdon,
will On the work.and the structure is mairmeded,urdliared fertile(Sec.7044.Business
and Prolcosions Coda:The Committees Ument!Law dna Out apply to an rainnia Of Required Inspections
property who Wild,or i mpmow thesecn,and who does such work hunatelforthadaZIS his
man employs,provided that such unprommoods me not intended or offered fortude.If,
harvemr,the building Or improvement is Said within one yeas 017complatim.the owner.
builder will have did besides,of moving chat he did Our Wild or improve for purpose of
sak.).
0 1,as..of the properay,am exclusively commerti,with licensed criarricuser,to
construct the ladject(Sec.7044.Business and Professions Code:)Ties Contraman's Li-
cense Law does not apply in an Owner of property who Wilds or impanva theater,and,
who conormucts for such projects inch a moneramor(S)licensed pursuant to On Cormuchor's
Licamm Law.
E3 I Sea caresn't under Sac. —.B Ar P C f"is reaccon
ime, Data—
WORKERS COMPENSATION DECLARATION
I hereby ellem under Penalty of perjury am of the following
0
motion,as provided far by Section 3700 of the Labor Code,for the Performance of On
mer,for which this poditis issued.
F1 I have and will atemen Works Compensation I.,is rectured by Suchm
3700.f the Lecour Code.for the postf.sch.c.1'the work far which this permit is I.&
MyWcalm' C I In Camara artier and Policy number ase:
caranne'. Sul. agani -71 SOO 152 1S4
Policy No.:
-0 1
CERTIFICATES F UWMON FROM WORKERS'
COMPENSATION INSURANCE
(retraction nand not So completed if the Permit is Want,hundred dollars($100)
or iCxQ
I modify that in On paxmince.of the work for which this permit IS Wood.I mail am
calplitymy person in my anantrum,so as to becorm,subject to ftWmrkvx`Coomparead.
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Centifiam of Exemption,you should
become subject us the Worker's Compensation provisions of the Later Code you most
Ofor"w'i"'comply with Such Provisions W dul permit She]Ito deemedinvoked.
z2 . CONSTRUCTION LENDING AGENCY
E4 1 barch,ifilres the than,its construction lending agency far the ,fo...f
> the work for which this Permit is listed(Sec.3097,Cry.C.)
1-cader's Name
D z Lenders Address
U 0 1 certify that I him head this application and soon that the exam information is
It. E comanct.I agree to empty with tit city and county ordineraces and state laws missing SO
C) building Construction,and herby indicate,rspureaccandmicuffbis city in mine,up.n the
above-mentioned property for inspection purposes
(We)agree to Saw,indemnify and keep harmless On City of Cupertino against
c,l liabilides.judgments.costs and ex,amene;which may in any my Ammon Ai mid City
U Z I.mummi...Of the 1.6.9 Of Oil sereaft.
APPLICANT UNDIfESTAN0,S, D WILL COMPLY WITH ALL NON-POINT Issued by: Date
so N 5; �
Re-roofs)6(
Sigmilins ofA,HCmVCO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding accurpeaftstom car handle hamordous material
as dellned by the,Cupertino Municipal Cash,Chapter 9.12,and the Health and Seely
cos",Section....2'a" XN. All roofs shall be inspected prior to any roofing material being installed.
0year
Will On applicant or future Wilding mmuport use equipment a device which If a roof is installed without first obtaining an inspection,I agree to remove
craft by Nous air contaminants SO;defined by the Bay Area Air Quality Management all new materials for inspection.
DiSuia?
Dy.
I have ratel the inuordaus theories mWirenumus under Chapter 6.95 of the Cetar-
as Hcalut&Safety Code,Scentions;25505,25533 ard 25514.1 undcamad leas ifft Wilding
iton net cu.nt1,h ve aan do my.'rehilk,to..at,the,occupar,or the
acquire ual I (a Cornfields Of Ommip"xi Signature of Applicant Date
;w— All roof coverings to be Class'A:s'or better
Owner or-;u—0.H.d r.—t. in