05080226 CITY OF CUPERTINO ^ '
BUILDING DIVISION PERMIT �CONTRACTORgNF�ORMV OW.
BUILDING ADDRESS: PERMITNO05080226
10465 GL E
ER'S NAME: PERMIT ISSUE DATE
JAY PRESTON 9 23 2005
PHONE: J s. n/ fnnasa SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER: WIA�R�O 2OOV BUILDING PERMIT INFO
BO O ELECT PLO O
goo
LICENSED CONTRACTOR'S DF.CnalofCON f(�Q lob Description
�+FF Iion7 affirm Wton on Sofa BuinlerprovWonsof Chopter9(rommevinj fr�v..�fO I�IJ
n z�`uf
withSectionI.=a0(efof Division 3af He Buencssand Profesaluv Code.and mylkevtu
in ran sera anderteck /REMODEL DINING RM
igj� Date cCless Conncmr AND KITCHEN
ARCHITECTS DECLARATION
I understand my plane shell he used at public records
c Licensed Pmfeuional
OW NEre muIrDER DECLARATION
ZOO hereby.albre(Sect that I1. enines; nopt WConaacmoe:rs My
for
mc
O O which rm mason(Section 703 Construct.
Business and w.dam l Cade:My Illy ar caunre
S$� which requires a permit to cnnnruct.alter.Wprmr,demolish.m repair any structure
prior In its issuance.also mquirrs Ne 9PPlium for such Permit in file a signed wtement
that he Is licensed Putman,m the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area VaIU 1�a 922
$ (commencing with Section 7008)of Division 3 of Ne Business and Professions Code)or
.. that W is exempt Nemfram and the boats for tie alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of APN Number Occupancy Type
not more data fiw hundred dollars(5500).
36911034 . 00
.
❑I,uowwr or',tae pmpenY•amY emplaym with wege.uthir sok canpenadan,
will IrNewark.and He atmnomurors License La does
Pply.7Dan onswewss Required Inspections
and enywhobu Cade The Catmecton, ndwho Law does or apply lf an owuer is q P
pmpenywW buipmidld,or mprosuch Improwmeso M mAlhanded nuelfm through hf.
ownemployees,Provided prawhImprovement,areno,year
ofdmofrered me forOwnde.if.
however,the building or Improvement is cold within r, you ofimpro for Ne owe of
builder mala have the burden of proving Nu he did ret Wild or improve far purpose of
�1.u mart,of the property am eaclusively contracting with licensed contractions m
construct the project(Sec.7044.Business and Professions Cade:)The Cwuacto'S Li-
canm law does not apply m an owner of property who bulks or impmws demon.and.
who contracts fm such project,with a contractor(s)licensed pursuant m the Conuanmh
Lieeme Uw.
❑Iammem under�9/e/�,.f / B h PP C for this mason
er C_lT� "1/IADe¢ 1
7_
7 Os
ORKPRs COMPENSATION DECLARATION
I hereby iflima under ptnslry of perjury arc of Ne following Ceclaratbm:
❑I haw end will mein Wn.CWficate of Covent m rel!-Insure for Warkel.Compen-
ption,as pmwIdcd for by Section 37M of the labor Code.for the performance of the
work for which this permit is howd.
❑I have and will maintain Worker's Compensation Insurance.as required by Section
3700 of the Labor Cade.for am performance of the work for which His permit is Issued.
My Worker's Compensation Inwrance Carrier and Policy number lie:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need notbecmnpletedifthePermit lalorwehundmddepan(SIOal
or less.)
I cenify that in the performance of the work for which this permit is Issued,1 shall not
employmy person In any morns, q m c tin Workers'Compemation
Laws of Califo alp�,��`��� '
Applicant {/ AP If.
l
NOTICE TO APo the ork If.ands making Nu Certificate a of Lalmption,you shuck
become subject y the Wren provisions
erovistov of the Labor Cale,. muss
.JO forthwith comply with melt pravitlov mNu permit.hall Ise decreed,corked.
'�ti CONSTRUCTION LENDING AGENCY
(-i Iherehy a(nrm that Nero isoconrtmndr.lending agemy l'nr the porfurmance of
? He work for which this permit is Issued(Sue.3097,Civ.C.)
aQ Lender's Name
i1. Z Lender's Address
L)Q I canary that I haw mad this application and sure tiW Ne show information is
Uy^ conic 1 agree,to comply with 411 city and county uselessness and stae Is"mhdng m
0 Wilding construction,and hereby authorize miumenutiws of Nu city to enter upon ft
{gl .1bove-men0owd property for Inspection purposes.
(We)agree m cave,indemnify and trop harmless the City of Cupertino slainst
ar TaA
liabilities,judgments,costs and expenses which may in my wry accnm against aid City
U in consequence of the granting of this permh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date I
SOURCE ULATI i .
_ l� g(Z3IVC Re-roofs ldJ� 3n
Signalum of ApplieanfiComntemr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building occupant atom or handle hazardous material
le0nod by tiro Cupertino MunWpal Cale,Chapter 9.13.and the Health and Safety
°•section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
w ❑� P4a
Will the applicant or future Wading Occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh bas ti uaaircwumloam s as lebrcd by the Bay Ams Air Quality Management all new materials for inspection.
District?
❑Yea OR4u .
1 have mad the hassrduus mamrialarequimmenu under .Chapler6.95 of dte Califar.
niaHcalth&Safety Code.Secdmu 23505,25533md25534.I underamnd tha,ifdn Wilding
does Out cunemly bean a tenant.Nat it is my resp.Chility as notify the aceup.,of the
mquimment,whto be me,e,ppri{,m�isssuanetancertine.teafcamps. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owbe/or authorized agentaD e el