08020124 CITY OF CUPERTINO '� .�.-'s:> %"- �"� ''• " ` "
BUILDINC.DIVISION PERMIT COb�ITR 'of,, 2 NF,U�.ATIO�! ':
eDat3�cfgl�eEslsi0MESTEAD Irr No.
RD LAGUNA MADISON INC. PERM 08020124
W NER'S NAME: PERNUT ISSUE DAM
ROGER BARNEY 3030 OSGOOD CT 02/20/2008
HONE: SANITARY NO. CONTROL NO.
(510) 353-1500
ARCHRECTfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�oij uceeslare 1, RAcroas DECLAaaION Job Description
uJ 1 hereby )of Net 1 sen fl c 8u under ftfcns of Chapin=9(000cncing
wiNSection]g9)of DivhionJaf the BmmsimueW Profcuiou Code.aW mylicemsse is VINYL RPLCMNT WNDWS 6, 1 SLDNG PATIO DR & 1 ENTRY
+Oft bfull force,socialism. gzZ5`3(w
5�z Lkense cm Lle.g DR ALL N EXTNG OPENGS & NO STRUCTURAL
g Dew 1 i 20 u mI Conuecbr
3
ARCHITECTS DECLARATION
W O I understand my plane Mdl he used As public reconk
;6
'0 1 Cleansed Professional
v,1 OWNER-exempt RDECLARATION
COO 1 museum.
.(B.that I I.S.exempt from the C.Iracto o :Anyc Law forco the
COO following m•."a.Permit
703 luBwhess and Pmfrssium Calc:Any dry structure county
S 9 which rtqui su n permit m construct.alar,impow,h permit t or epaig any w -
Z<
that
he is l iuuanco,aim oquims thprovisions of rorsucthe Cort permit Lice se Laved mneme=
p Nonurn lis,withSectan70Ann 00)ofDofWConuacbbLi=nselsosCode)r9 Sq.Ft. Floor Area Valuation
y�$ (commct axe pth Section and
ivkionr the
the Budnensandon.Any
Code)or $9142
thus io u exempt thyroli and de burs for ubj ukgW evmpu..Any violets.of
.1 Am w]Dred by any applicant for a permit subjectssubjectsthe Applicant a pull penalty of
rot mom taEvahundrtd dalWa(f500} 32651006 Number Occupancy Type
❑1,ummrofthepmpeoy,ormymploycuwlthwageeuthekwieeompcmdm,
wiBdothcwrk.mdthenructuoi3.tiondedaroffmdr.ule(Sec.TO44,Businea ns Required Inspections
end Poland..Cat:The CmAneme,Li..Lew dao not apply b an owner of q P
property who Wildsarimprovu thenen,and wWd.se.h work himselfor Waugh his
own employ=,provided that such imProveoems tae not intended aroRetrd formals.It,
heowwr.the building or Improvement is cold within one yev of completion,tate owner-
builder MB hew the burden of moving Just he did An,Nita or Impound for purpose of
tale.).
❑L u owner of the property,am exclusively contracting whit Hameed c rommse to
construct the project(Sec.7W.Business and Profession,Code:)The Cmuacter's W-
cooea law doss mat apply An an vomer f,.,my who Wilda ar ioprows there..And,
who contracts for such pojeme with amnuscoRs)licensed pwsuml An tae Comrsowea
License law.
❑IamexemptunderSm .BAPCImd,isreuon
mr Dew
rr WORKER'S COMPENSATIONDECLARATION
I hereby affirm under penalty of perjury one of de fallowing declarations:
❑Thaw antlwBdfor by o 37M of Co Labor ode.furt epedweh Canpane
tarok,r moulded far mi Soon..name.3]00 of tae tabor Code.for ds paRo.ance olds
ooh for which Nis permit u iesucQ
❑1 haw and will maintain Workers Compensation Imuran,As no,wred by Section
3]00 of W Labor Code,for the perlowuce of ink wok for which this permit k issued
My 1Workers1 Compensation Insurance artier and Policy number am:
ry
Caer. NCn,N 4o Ol Policy No.:51-F GPr11�L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Trids need.coed rot W completed lime permit 1,fort mhundral dollue($IO))
or leu)
I=+try dent in the performance of the wort fee which this permit 0 issued.I shill not
employ any person in any mannerm u in become subject to the Worked Compensation
Lows of California.Dow
Applicant
NOTICE TO APPIJCANT,If,after making this CeAficene of Exemption,you should
become subject to de Wo wens Compensation provisions of the LAW Coda,you must
.,O forthwith comply with such provisions or this permit shall W doomed mated.
y CONSTRUCTION LENDING AGENCY
ai
the warkherewhi�iNta��1e is a connection lending agency for Nc performan¢of
017 the work Name ornnk is mount(Sec.3097.Civ.C.)
Undoes Add.
U Q 1=nify Nat 1 haw wad Ws applicuim W we that the show imowetion I.
U.P correct.I ago to comply with all city and county ordinances aW mute toxo relating he
QU building combustion,And hereby authorize representatives of this city w caner upon the
ITa shove-memianed property for inspection purposes
py (WA)agme in taw,indemnify and keep harmkat the City or Cupertino ageimt
h limilides,JWgmems.costs and expenses which may in any my amuse against sud City
U Z in consequence of the growling of this permit.
^' APPLICANT UNDERSTANDS AN91 WILL COMPLY WITH ALL NON-POINT Issued by: Date 2 /
SOURCE REGUL11 7015
-ItL°I`° Re-roofs
Signuurt or ApplicitatIC.Ammum Dew
HAZARDOUS MATERIALS Acxup DISCLOSURE Type of Roof
WIII the Applicant or future Wilding e.Chap Jae grand le mash Health a material
u de)nW by de Cupertino Municipal Code.Chapter 9.17.end tae Health owtl Safety
Ar ,lA,S.cfm25532(Q? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �r..�-
Will the applicant or filum building occupant not eyuipmant or do,!.which If a roof is installed without first obtaining an inspection,I agree to remove
em)t banal us tar canuminanu As defined by the Bay Arte Air Quality Management all new materials for inspection.
DiautO
Dyes 909
I hew mad the baccom us materialeroquimmemunderChapW6.95dibeColifor-
-is FkahhBSafetyCude,Seyou 25505,25533 uu125534.Imbcssund theifde Wilding
does rot currently hew.to amglwt It is my wspommnity,in entry the s==tem of de
reyuimmmmmwhmn we 6Etpriorainsammor,c ne.war�enmmy. Signature of Applicant Date
owner artamarived.gam
Do.
All roof coverings to be Class "B"or better