05110114 CITY OF CUPERTINO A i% 4 tsa.�+ttr a4'bi
BUILDING DIVISION PERMIT S�CONTRACTOR INFORMATION
BUILDING ADDRESS: PERM"N0. 05110114
10339 BYRNE AVE
OWNER'S NAME: FERMrl'ISSUEDATE
. ANDY DEBAETS & REBECCA SMIFH 01/25/2006
E
SANTFARY NO. CONTROL N0,
ARCTUTECTrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo� LICENSED CONTRACTOR'S DECLARATION Job Description
C ^ 1 booby dam u u I un Imonmo under pmriu«u a Chapter 9(airnn l It P
U NSrfortm.dtfffDlvubn3orNCBwno.ud Profuuou code.arA mylkcna�
in full r«a oma a DEMO (E) HOUSE
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AR"Ilx S DECLARATION
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O.1NER-BUILDER OP t ConTION
�po3 1 hcrtby_(M.S= Nn I 1 eacmpt Two the Gtun.C t lunar taw for ds
falWwingwan(Salm]0715,BWneu and Pm(esuum Code:Any atyurmunty
$ which rt,W.a Irc.it In crosnsL.lwr.Improv,demduh,Or rtluir any st,=urt $11800
Prior to ler iuuucc.alta mquirts dsappliuru for soh Permit m Bk.signdsUmOnot
£ <
thin lruliccnavlfmnuuumWcpmviumunfNCCmuerorilicuxLaw(CMPW9 Sq.FL Floor Area Valuation
y (mrn=ndn&with Sallo"]0f10)of Diviaw 3 of mC Bud s 2nd Pwfuuora Cools)Or
yu dm be I.aanpt t from"We bait for rbc Yk{d,..mpd.My nUsu)on of
Sad.M3 13 by any spplkam for is Parch aubjau Ne.Ppl ma WW1 PouhY of f` 11 Occupancy Type
imp mac m.a fiw hodmd dalun(5500).
❑I.u owic of ds propmy.«mY uvPloym wW wa6es u thew>ok aampewtian.
will do lbo wrk." ftsrr"ameunut"¢nOcd«OBaed for uk(Sm.]O.L Buunot Required Inspections
u.d Pmrauam Coo:The emlraClara Lixaz tar don int apply if a"awoer of 9 P
progenywhobuilds«imprawumono.,timid who don ouchwort lriff foul h4
own an,om govWetldw sshImProld a mererut BueMW«fka ,rn 2.1e It.
bowav,me bwft «Mpro pro nu sold did Out
you of e«o fix the oait,of
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du1M wIIL Nae the boNm of pmvint mu M did tut bdW«impmw(«Puryts a
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[�'(u owcr of do popcnY..m c2cluu.cly ca"vaNn{wiN 4¢vad wnrnnon m //
cor5VRC1 theproka(Sec.]BM, of lurnd Rawh"bun Co orbri eCa"hams Li. 6
mruc taw don oa.Pplr je m ower ar Water s)ll"ddW i«ImPory Cuums and.
wpm cmuuu for ouch Rokw wiN•co"vacur(s)Ilaucd Durmau m Us Canrrcsa(t
Lkeme W.
❑lam ef/umpluMo See / .BAPCf«Nit
Dare
"� WORK SCOMPENSATION DECLARATION
I herrby a(fbm miter p®Ry a perjury me Of de fdbwity d IsrUlmc
❑I W w.M w01 maiwin.Cenllicnw of COmem m w3f-Wsum fn Wanda C«nperf
fart"R u ProvW W for by Sm 37/(10 of Ne Isbor Code.for Ne Perfann.«e of Nc
wart for whkh mu Pcrmit u ianW.
1 Woe ud will outrun.Wm '.Compemslm manna,is m uhW by Salim
3Ma the tubar Cock,for me perfarm.aa of the wart I.wbkh Ihu Permit u imd
My Wortelt Com, ^••.m Wwarue artia.rd PO:iry rumba uc
csrrkr. Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERT
COMPENSATION INSURANCE
(ibuxNmrmina.becatplaW If the pumhaf«am hurtGcddrillan(SI W)
mica)
I unify dmI In the perform�a�i«fof tho�woO4 rro,which this parch It unit,I uWl"or
anyloyu pomoriniany tr/_S'LO 1. _mbkc+t^uie wahrn•eam?"•• m
"m or caBforBl�Dae .
Applicam�_�� .•���`
NO CETOAPPUCANT:IL ewr matin#Nu Ccnlllwc a EacmPtion,you ahmW
boom,mbjal w me Wor as Campcuatian pmviuou of ds Ls «Critic.you muu
.J Q rorthwidi mmm wovubu«
ply wIch prmu permaw
it l bo damcd
rt,akcQ
?2 CONT]BucnoOiLENDINCACErcY
[-..n I bercby affirm dm mcrt us cmaWl{an k Injsii rc fm ds Pafuion—of
fY> me work f«which mi.P a is imud(Son.3(91,Civ.C.)
Ow. A ILndds Num
'=z Lo a ,Add=
U0 I m fy mu I Ww rod mu appliwion and saw t1u me show ororiutim u
U.V corrin 1.{rte In comply with all city unit county on iw.es ad mw lava rtudn5 m
O boilth,conYncliar,and bcmby aRlhnrlm rtpmxnmiwu of this sty W mrcultotM
LU .Mw ntio"ed P ny for lmpectim Purpor.
(We)alpce In um IodemWfy tad kap harmku ds City acupwioo a5ai"n
rttzI lubilitit.jWt ts.encs sod e.perwa which may in any my a(QRe ajaiul said city
U 4
in of this�Jt.
APPLco ICARNT UNDERSTANDS AND WILL COMPLY WITN ALL NON-POINT Issued by: Date
SOUg REGULATIONS.
2-5/ti 6 Re-roofs
Slpwmc aA0P1� HAUIIDOUS MATERIALS DISCLDSURE Endo Type of Roof
WIIIdwoCotstot«rM Pjij Cps Ouptatem WMkb tliand Wn y
u defud by ds Cupenhw Muvldml Coo.CW Pus 9.11.and me Fiwm.nit Saftty
Sss53xa)' All roofs shall be inspected prior to any roofing material being installed.
❑.aim Ya
W311 me yrpliauu«rw.rt bWWinS aceup2nl.¢equlPmrnt« which If a roof is installed without first obtaining an inspection,I agree to remove
curb huarMeu err m"umimnu u tkfuwd by dw Buy Arta Air Qualry Muupcmant all new materials for inspection.
DlWicl'f
❑Yn tliRa -
1h r the hoodoo mucriau rtyulrcmcw umIo,C1mpitr6.95 a ms Califar.
nit tblthk SafetyCode.Sa 25505,25533 ud2553/.1 ur.baud ms ifine bWIdxij
dmi Out CurmiWy IMNo a wmnl IWl it is my rnpMl Wty m mdry me aiuPMI of NC
rt oirxorenube mel mnm of.cmifeaw a 0C.T..y. Signature of Applicant Date
)1-1310 G All roof coverings to be Class "B"or better
QYmr«a nmrircd apim '02w