06020112 CITY OF CUPERTINO T + a 'W r
BUILDING DIVISION PERMIT s,C0NTRACTOR»INFORMATION 4
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BUILDING ADDRESS: MARY JO RUSSELL GUNDERSON PTRMITNO.06020112
22074 BAXLEY CT
OWNER'S NAME: PERMIT 0SUE DATE
Aft MARY JO RUSSELL GUNDERSON 02/17/2006
14 E: SANrrARY NO, CONiR01,N0.
ARCHIIEC rENGINEER: BUIIDINO PERMIT IWO
BLDG ELECT PLUMB MECH
zZ � 0
.0p LICENSED CONTRACTORS DECLARATION g UOn F 1 hmm N
eby afEret I un Ilaoecd under pcoviuu mJob Description
or Ch.psr 9(mm
ncinE
4 `u MN Secrim 7")of Dl Wim 3 of the Bunrcs,utl Prolco ions Code..rA my licenau
in Odl(arm and cRem REPAIR (E) DECK @ REAR
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3 -{ ARCHrEC1s DECLARATION RVA!
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3 a
OU Iun&rcomd my plsu alud,be usd u public meax
u. Lkccncd Prud.,,n nal
dap OWNER-BUBDER DECLARATION APR / )f}
d� E I hcsty arirm tha 1 sm ucmpt form ftCanuaclu,IJmns law for ft �_
p o follnwint reason.sccuun 70313.Buslnus am!Prafosiun Code:Any city or county
$ which requ4u a pctmit W madrucr.altm,hnpm.e,xmol4h,or slNr any arucws ,a ..k$3 0000
prim to its 4suarcc.rdm rouiro tic.pplkwt fmach perrvitto flit,.,itmdsacmcu
EE < the ho Is limucd puocunl to Nc pmrisimu of ftCaar.cmi Bans taw(Chaptc 9 Sq.Ft. Floor Area [�}g ValUatniofi1l,�
y C (commenoint with Sectian7IXp)of Doislrn 3 of the Pon.and Profmion.Cale)or JlSar--ynaj
}I
that k is eacrupr Cesfrom and Be basis for Cc allctcd nempdm Any Holston a( G 6
Seulaa 70315 by.1.1plimu far•P.0 cubic is the applicant to•ci W peoally of
nal torr thw BK buwmd dollar,(M). r Occupancy Type
❑1.as w=of the POPaly,a my=ploy=with warp u den mle comCm• nota
will dote Mon,stdthe Inv
lMtdo o(4rtdr"@(Sm.]Ma,cov=II
and Rolewlam cox:The cmerwt,ureAe law tiro tai apdr la.n awtc of Required Inspections
ptoPccmpt. pyovisd0.1uchewmumchwbo due,ouchwncicd.slrathrmNhf.
owns bcwo�'uuma,prorWri tyro hImps aclii it ion mt'vucMed IXrnertd for sok I-
Wilder,dsari int omd,o o frond uhod didnmeyearofcnforwOfo,Neowar-
hullxr will hare dK Nutlm of pmHot Nu k did.m Mull o amprma fo puopas of
u .)/
cornscu owrcf oj the SOc.7 .B excess sod coon.tint with Hamed cronuactu,to
cm,mlm des;our (Sec.toad,Business and y who builds
Cox:)The Coaucwf.and wtue law dons ria apply en an owns of property who sedd,or impm.e,Centro.and
who contracts for such projett,with a movacar(a)IlmtcO punwnt m Ne Cmv.clor'a
Lkxns taw.
❑Ian cya�e�m(p,�t o^^��,, Sce. B h P C for 04 moron
Owner yl - Aa/� catei119(oY .
I/ WORKERS COMPENSATION DECLARATION
1 hereby affLro unser penally of peoJ arc of Nc folk,wint dalarariats
IIsi as and willtor by section
ave Of the Labor
rJ ,fore fo Woksh of th,
worm. r Provided for i Salim 3-100 a(the lather Code.far the perfarmaa¢of do
nark for whiN this pemtil i,iaucd.
❑1 hair artl will maintain Woksr a CmopenwJm Iovaysa,u nyuisE by Section
3700 aNC Lathor Cox,fa the perfarmuae of de work for whkh d4,permit 4 4Bed.
My Wockv'a Cmnpenution Irso aur carrier and policy combo tie:
Carie. Purity,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tb4 seNm Iced not hecumpitcd BCc permit 4 fIXane hustAed dol Ws(5100)
M lCw)
I certify that in Ce pmf.mr.of the wok for which this prnnit 4 asmd.1 shall and
employartypormninwY m. pulO�—subjectoothe Workers'Compewtbo
I aws Calilprola.D. 1r�10
Applkuu
NOTICE LICANT:If,after m&Hn,N4 Ccnafcae or Eacmpunn,you aauW
became sub}ot to tho Woher,Cmapetwrian preri,iuru a the IabIX Codc,you mond
.J2 forthwith comply with out prorWam or this permit shall be dremM rewked.
Z O CONMUCDON LENDING AGENCY
Ihcsby.ffrm that here 4,mrwrmoiot kodint.pcoy for Nc pafomsaaa
y' do wan fo which thou permid'u issued(Sec.3097,Civ.C.)
Q (<Mcf,N.
= z Icmice.Addru,
U O I ceNfy that 1 haw rod N4 applkaim and ...that Nc.Fore infomadm 4 .
I,F cones.I atrct to comply with all city sol candy oNlnaoces.nd stab,laws mluint to
0 buildirt construction,and!hereby authaim rtprrxntatides al this city to testa upon the
bmc-mOrdR cd propmty for Vorou um purposes,
0. (Wc)agrm to saK,indemnify std keep h.rmku 0e City of Cupmiw.pulvt
fn liabilitio.judtmonta,cm4 ud Saprnna which may in.sty way...a toms,said Cry
U 2 in emuuueRc of Nc trading of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT Issued by: Date
SO(X REt'aULATIOF . - / 2��7�Uy Re-roofs
Sitrmm ofA iawVCrnor.Ho
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WBI Ne applicant or forme bWltlNt occupant Som or W odic Wardous material
u defined by the Cupertino Municipal Cox.mapter 9.12,and the Heard,anti Safety
code,Secumss532(.)?❑ All roofs shall be inspected nor to any roofing material beinginstalled.Yer�
Will ds applkunar fuwo buidintoccupam uscequipmcaro decries which If a roof is installed without first obtaining an inspection,I agree to remove
ttnit huurdou.il cants imods u cfrcd by Nc Bay Arca Air Q thly Mma,c,mot all new materials for Inspection.
Du n7 /
❑Yn �1
I hoc mad the by misundo ClupW6.95orrisCalifon-
ma T 1"Safcry Cadc.Secumu 25505.25533 and!Z5534,ItudcmarW dteirtbc building
docs not cum"hart a lar n that,It 4 my ropmrvhiny m notify Ce oavpanl of are
7 ^retnenuwhk mm,R_,b/ out fmorqoumccofaCcnificaltor � Signature of Applicant Date
Y6' "- ""`/ Z-1t" � All roof coverings to be Class"B"or better
(3wner auNmisdatcno Das