08100045CITY OF CUPERTINO9
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BUILDING DIVISION PEP
CONTRACTOR INFORMATIOO1�f" -
-MIT
_
BUILRqINC A DRESS:
PERMIT NO.
G13 4 DEXTER DR
TBD — TO BE DETERMINED
08100045
NER'S NAME:
FFRAUT ISSUE DA'Z'E .
MITZY & ERIC BUTTE
10/08/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHIIECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT RUMS MECH
LICENSED CONTRACTOR'S DECLARATION
1 Job Description
P
1 thereby art ire then 1 w limmnd under pmvisioru of Chapur 9 (mmmeming
wiNSccdm7")of Divioon3of,k Businmmd ProfcWum Code andmylucnrala
RMDL KTCH(122SQ),2 BTHS(127SQ),NON—STRCTRL;E/P/M—
Licensell aeaMercece � Ltg
NO RE—RF OR STRCTRL '
NOTE: DBL CONSTRUCTION PD FOR BUS LIC 10-8-8
��]g
Dat ARCHITECTSDECLRRAM
1 unM.raund my plains shall W used as public heeards
Lktved Rufcasional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 m eumpt (rare the Conuamols License Law for On
following meson. (Section 831.5. Business and Pmfrssiom Calc: Any city of mumy
which not, fres a permit to carliWL4 also,. Improve. dererlluh, ar opal( Ny -WClam
prior b it issuance, also hequihea the at,dicant far such permit an file a signed sWcment
Cmuutola U.. Law (Charter 9
Sq. Ft. Floor Area
Valuation
thatW is licensed Formant in thepovuiaruaf tW
(commencing with Section 9008) of Division 3 of three Businessi nd Pretensions Code) or
$70000
that he is saernPt therefrom and Be basis for the alleged caereption. Any violation of
32641073.'CIV'
OCCU
Occupancy Type
Sermon 1031.5 by ary, applicant far a permit subject the, appgaal to a civil Penalty OfNumber
not mase dila five hundred dollars(SsoeL
❑ I, u owner of the Fmpmy, of my mploym with alga u tbo4 sole mmpemadon.
Required Inspections
aid and the moRe 1014....of
dims;.1 a(Sec.
and Profusions Cade The ConuacmM1 Limnat Law dor nal apply m .n owner
Profession.hecintunotuLt.
is
pmPenywW builds me who thimvlfm Wough his
iimproveschhan, Sacan, im for sok If.
that such impsmemenu art mt ea:ndnd m
awn mpbyeWilding
atl llaetl
however, the Wildingorimpmsemmtemit within am Wild owner -
mproefoor
in pr
builder will Nw tit WNcv of proving that be tlitl not Wild er implore Ter Purpose of
isle.).
❑ I. u owner of the property, am eacluively contracting with licensed conaactm to
compact Ne project (SCC 1044. BLLtinean and ProfcsfiaN Code:) The Commences L4
come Law dm not apply to in overt of property who Wilds of impmw thereon. and
who mntrdls forsuch pmjCm with a mndaaod.) licensed pedi In We C.Mosel rs
U,com law.
❑Im ..at under see .B&PC for this won
Data
WORKER'S COMFENSATION DECLARATION
I hereby affirm under Faulty of perjury one of sit following dealafuiou:
haw and will maintain a Certificat fC..., to u1f-Insure for Workers Compen,
Stion. as provided for by Session 3100 of the Labor Code, for Ne performance of the
'
wort for which this permit is issued.
❑ 1 haw and will maintain Waran's ComPemation Imuran¢. as myuined by Section
'
31110M tht labor Cod., far the pmramance of tW wart for which thu permit is issued.
My Warkefs Corporation ham. carer and Policy number art:
Curiae Policy Na.:
'
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Clldn smdm reed not be cmnplctd Vote Permit IS fame hunched do0ars (31M)
or leu)
I certify this, in Nc Perfa once a tbo ark for which Nis Permit u issued, l Nall not
cmplayanype inanY �, t (c rbjeclt Ne WahcK Cmperatim
4ws of Calif aIs
Applicant
NOOCE . after mating this CerOcat of Eumption, yes shmld
become. b Ne hers Compensation Provision of the Labor Code, you mud
foMwith comply with ch provisions car Nu Permit shall be dcemed ranked.
I
i CONSTRUCTION LENDING AGENCY
I W mhy Still. that Nem is. eonsaacerso lcadm,.(Cray far the perfumute of
the wart far which this permit IS iuund (Sec. 3097. Civ. C.)
'
Lenders
leaders Addw
I unify that 1 have read Nis application and sum than the Show information u
' coma 1 agree in comply wits N city and comty, onliunm and sum laws heusing to
'
Wilding co earema . and hemby+uNmice ropiesenusivca of Nis city to enter upon Ne
I above-mentioned PmPenY far imPectim purpn¢L
(We) agree to save. indemnify and keep harmlm the City of Cepediao against
j liabilisica judgments. case and eapeasta which may in any way areae against did City
I. consequence of the granting of this permitt. /1
' APPLICANT UNDERSTANDS AND MLt,tI¢OMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS L/Yfg1'/�/(_�A{y'/
—
Re -roofs
Sigmurt of ApplicanVContrdaor Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will thro applicant or (utme Wilding accupanl score or handle havmdous metrial
9.11 and sit HaIN and Safety
defined by Ne CuPeNoo MuninpaH.,Pmht
. Servan zss3:ca)T
❑ Yu a
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant ar ramhe bease equipment or d.vtm which
emit haurdam air contaminant an dc0 ay Asa Air Quality Management
all new materials for inspection.
Dista mT
❑ Ya ❑
Iha ad the hu at smnti nesuadcrC'hapterf,950ftheCaiifur-
nuHalde S ctyC 25W.35533d B534.Iwldcruond Natifthcbu0ding
dm ret Y his it i my mp.nsibilh, to cosi tht .pent f tht
,
require h rtoise.of. Cmtifeat a
Signature of Applicant Date
Wvp
All roof coverings to be Class 'As' or better
Ow mhamt em Dat
2