07120267 t
r
CITY Or CUPERTINO � 7�^
Yy*,gi a.
BUII:DING DIVISION PERMIT Q�1 �14� M "I
PERMIT NO.
BUIIJ)III(y/fgR PATRIC CT CRITCHFIELD CONSTRUCTION 07120267
NFR''SLNAAMlE; PERMIT ISSUE DATE
MATS & MARIA OBERGE 845 S MCGLINCY LN 02/08/2008
PHONE: SANITARY NO. CONTROL NO,
ARCHITECrfENGINEEK: BUILDING PERMIT INFO
ADD 1158 ' FMLY RM, DINING BLDG
O PLUMB MECH O
�oo LICENSED CONTRACTORS DECLARATION
^' _. escr. ] .Dl tion
�r 1 hereby arum that 1 am licensed under provisions of Chapter 9(commencing p
Section7deflof Oiviekn3ofthw eudneas antl Professknn Code.antl mylicense is
I.fall clans. dffea
License In Lie.Is
�^ Dem 7 Contractor
ARCHITECT"S'S DECLARATION
1 understand my plans shall he used u public rtcoNs
U
50 Licensed Pnicssianel
OWNER-BUILDER DECLARATION
I hereby eller that 11. exempt s an the Contrmtaas License Law for the
O O (allowing moon.Permit
t 7031.5. t.steer and Prerm demo Code:Any eiry or county
$ which requires a permit re construct.alter,hnpmw,d permit,or mash any somatom
prior miu issuance.alio equips the applicant(Grouch permit to file asigncd sulemenl
<
that he is licensed pursuant mthe provisions oftheCommoner LicenseLaw(Chapter 9Sq.F FlFloorArValuation
B (commencing with Section 700y)of Division 3 of the Business and predications Code)or
^ this u he exempt modefrom and the basis for the alleged exemption.My violation of
on
Secti7031.5 by any applicant for a permit mbjccu Ne applicant to a civil penalty of APN Number Occupancy Type
has mart Nan It.hundred dollars(5300).
❑I,uownuofthepmpeM,mmyemplayenwiNmgnuthekmkeompenaadon,
will do the we&.and thastructum 6 notmunded or offered Rustic(See.7044.Bumse. Required Inspections
and Pef carions Coca:The Commoner's License Law dean ret apply m an owner of q p
pmPartywho buihdsorimprovulhercan,antl whadowsuch worklimselforthrough his
own employees,provided thatmch improvements art not intended aro@red forsau.If,
however,the Wilding or improvement is sold within ore year o(completion.the owner.
holder will haw the burden of proving that be did ant Mild or improve too,purpose of
ask.).
❑1,u owner of the property.am exclusively contracting with licensed mntrscton to
construct the project(Sec.7061,Business and Professions Cade:)The Comecures Lt.
cases law does not apply or an awnsr of property who builds or improves thereon,and
who contracts for such projects with a conrxtor(s)licensed panus.to the Conuaclm's
License law.
E]I am exempt under See .B&PC for this moon
nsr Dam
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ons of that following declamdoes:
❑T haw and will for by
n acaum 37 0 ofCoue Labor
Cod iuum lm Workman ce of the
titian,u providedhhi far mi Section 3]00 of the labor Cade,for the performuxx of the
work for which this permit is issued.
[�1 haw and will maintain Workmr's Compensation Insurance,u required by Section
I700 of the labor Code,for Ne pedormance of the wohfor whkh this permit is issued. '
My Worker's Compe�ehnhte ion Insurance carrier and Policy number am:
courier:/ .NCs 1&'v &t?vt-'PnaA_PoliryNa.:V34OOI4za 1—
cc
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This accord heed"ot be core plead If Ne Permit a for enc hundM dollen(SIM)
or In.)
1 ceNfy that in the performance of Ne work for which this Permit Is heaved,I&hall Me
employ any person in my manner so u on become subject to thW Worked Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making NM Ccrtifiate of Exemption,you should
become subject m the Worker's Compensation previsions of the Laker Code,you must -
v'O forthwith comply with such provisions or this permit shall be doomed mvoked.
'Z rrNiCONsTpLfcnON LENDING AGENCY
[r I hereby affirm that them is a commuctiwn lending agency fm the performance of
CL
the work for which NM permit Is Wood(Sec.3097,Civ.C.)
W Q Lmakes Name
Z Lender's Address;
U Q I edify that I have mad this application and some far the abaw informeuun is '
474 ^'. moment.I agree m comply with all city and county adhousaa and sum Iowa relating to
_0 building construction,and hereby nuNarim representatives of this city to owner upon Ne
fJl .how-me"uuned pmperty for inspection purposes
W (We)agree to sew,indemnify and keep harmku the City of Cupertino against
n,t l'A
U Z in consequence of the granting of this permit.
IMbilides,judgmW ense cncosts and expwhich may in any way accruaagalnstuidCity
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date —off
SOURCE REGULATION i 6L/U$/OB
Re-roofs
Sgnuum of Appli dr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant no Insure building e.Chapter
Dore m handle Health
maurial
de.Sed Section
the Cupertino2(.)1, Municipal Code.Chapter 9.11 and the HnIN.rad Sekry
de.Sc yes z553z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �No
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.1 agree to remove
emit bosom ..air caotsmirmo s as defined by the Bay Area Air Quality Management all new materials for inspection.
Dimict9
❑Yes ONO
I haw mad this huardous materials requirements under Chapter 6.95 ofthe Califor.
nia Health&SafctyCodc,Sections 25505,15533 shad 15534.1 underaund this if the building
does not currently haw a When,fan it is my responsibility m naury the Occupant of Ne
,equipments which must he met prior to issuance of a Ccnificeu of Occupancy. Signature Of Applicant Date
'D2/68 V All roof coverings to be Class"B"or better
water or nut fdagonP Dam'