09060081 CITE'OF CUPERTINO PERMIT
BUILDING DIVISION PERMIT � � MsrI�l 1.
BUILDING ADDRESS: PERMIT NO.
10201 AMELIA CT GIA CONSTRUCTI
OWNER'S NAME:
PERMIT ISSUE DATE
l� �lA CONTROL NO.
r.,.SNE: IST
(408) 85:3-6316
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o p LICENSED CONTRACTOR'S DECLARATION Job Description
cu C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
ea with Section 7000)of Division 3 of the Business an ,eions Code,and my license is ADD 5 0 S I TO ENLARGE (E) FAMILY ROOM I NC LD S
r„ in full fore and ell
j r�Z Lice CI Lic.M
+� Date Contractor STRUCTUaAL NO REROOF.
CHITECTS DECLARA 1O
I understand my pla shall be used as public records
BUJ
OH Licensed Professional
y 3 OWNER-BUILDER DECLARATION
t 1 hereby affirm that I am exempt from the Contractor's License Law for the
%00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K$Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
n Z a prior to its issuance,also requires the applicant for such permit to file a signed statement
£_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor Area Valuation
y F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 5 0 0 O 0
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(M)O 3 2 617 01 a . 00
❑f,as owner of rhe property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale I[,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
r,Wner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,its required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wor!g Compensation]nsursnce carrier and Policy num ram:, T
Cartier. ��l�liry No.: Q 19 K `—0
C RTIFICA O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('This section need riot be completed if the permit is for one hundred dollars($100)
or less)
L certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z""' CONSTRUCTION LENDING AGENCY
E r►�+ I hereby affirm that there is q construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
z [.enders Address
U 0 I certify that I have read this application and state that the above information is
V1 " correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
12.
col liabilities,judgments,costs and expenses which may in any way accrue against said City l`�
U Z in consequence of the granting of this permit. Date
t-+ APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NO -POINT Issued by:
SOUR GULATLONS.
Re-roofs
Signature of Applicant/ onLractor Date Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle humdous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes 14No
Will the applicant or future building occupant use equipment or devices which If a roof i:.installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m 3terials for inspection.
District?
❑Yes t4No
1 have read the bazardow materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,;5533 and 25534.1 understand at if the building
does not currently have a tenant,that it is y responsibility to notify occu t of the
requirements which must be met prior to i anccofLCcftificata capan Signature of Applicant Date
All roof coverings to be Class'n"or better
Owner or aut orned agent Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10201 AMELIA CT CONTRACTOR:GIA CONSTRUCTION INC PERMIT NO:09060081
OWNER'S NAME: MICHAL DANEK 1645 EBERHARD ST DATE ISSUED:07/16/2009
C R'S PHONE: 4088386464 SANTA CLARA,CA 95050 PHONE NO:(408)558-6316
LICENSED CONTRACTOR'S DECLARATION " f— j"
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# C)p2�. f— -
r o „e MECH RESIDENTIAL COMMERCIAL
Contractor 6"1_/ Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD 50SQ TO ENLARGE(E)FAMILY ROOM
(commencing with Section 7000)of Division 3 of the Business&Professions INCLDS
Code and that my license is in full force and effect. STRUCTURAL NO REROOF.
10/05/2009—REVSN—ADDITION&REMODEL REVSN TO
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$50000
permit is issued.
APPLICANT CERTIFICATION APN Number:32617019.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature 1'1 Dateo 0 ei Issued 1f / Date.
? -
D OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
constrict the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
i ify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
c� aid expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18• I understand my plans shall be used as public records.
Signature Date Licensed Professional
v