03090095 CITY OF CUPERTINO �"'^' ' '^w^4 $ '" "�`' " 1'•
BUILDING DIVISION PERMIT �,CONTRACwTOR,INF,O' RMATTON
BUILDING ADDRESS: MATT ORVICK PERMIT NO 03090095
ERS NAME: PERMIT ISUB DATE
C
MATT ORVICK
NE: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMICH
0 0 0 0
�oo LICENSED CONTRACTOR'S DECLARATION
w V 1 Mmby.fritm Nat 1 am IPmawd under pmvisiom of Chgner 9(commencing Job Description
Lk.
th
wiSection 7M)ser Division 3 trod,Business add Professions Code.and my license is
n mLenmmaand,R`m'
License Clefs ADD 320 SQ. FT. /GARAGE 440 SQ. FT.
q Z L
�^ Date Contractor
j5ARCHITECTS DECLARATION
jy I undcrsund my plain shall he used as public mcnNs
0 Licensed Pmftssional
OWNER-BUILDER DECLARATION
EMO 1 hereby,from Not 11. exempt num Ch,Coxid.Code:
s :Any C law for ode
EMO following moon.(Becton]cont. t,Business and improve.
dentes Co de:Any citymcounty
$� which mqulro a permit m construct,alter,improve,demolish,or repair any nruewm nnn
ser
prior o its issuance,also requires the applicant for such permit to rile a signed statement
C that he is licensed pursuant to the provisions ofthe Contractor.Liccnwnw(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professional Code)or
that he is exempt therefrom and fee pais for Cha alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of 31Wb120ifter00 Occupancy Type
not mom than five hundred dollars(5500).
❑1,As owner of the property,or my empltyco wife wages as,their wle compensation,
willdo Chework andtin:wtqumisnmtinendedomnew finale(See.70M.Business
and Pmfeations Cad,:The Comrwmra License Law Own not apply he an owner of Required Inspections
propman employ b.provided that mprows
improve who dmuuetende himwlforthrsad his
own employee,provided or that such improvements wit am re intended moncutl the owner.
builder
however,the building or Improvement is hold within oro yet of completion,the owe of
builder witi Mw W burden of proving Net he did not build m improve for purpose of /
Ask.).
6
❑has owner of Che Sec.property.am exclusively and Professions with:i The
contractors w _ 1
construct Ne project apply
to n Business and Profusions Code:)The Conoacwris n /
cense law alms not apply m an owner of propemy who builds or improve tiereon,and -who contracts far such prejeco with ecmnuwmr(Q licensed pursuant w the GmnV61Ma
LicenseLew.
01 And
t s < ,B&PC fm this n
- er Date 111')10`
ERS COMPENSATION DECLARATI
1 hro ereby affirm under penalty of perjury oof fee following decimations:
I hoe and will maintain a Cenificeu of Consent to mfr-mus,for Workers Compere
anion,As provided for by Section 3700 of the labor Code,for the performance of fee
work for which its,permit is issued. -
❑I hoe And will maintain Worker's Compensation Insurance,As,required by Section
3700 of the Labor Code,for the ptr ormmm of the work for which this permit At issued.
My Workces CnmPensadmi Insurence carrier and Policy number am:
Carrier. Policy Nm,:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Ihiswetioo need not w completed if the Permit Is Fermat hundred delon(g101B -
m kis)
I ceniry,that in the performance of the work for which this permit is Intend.I dull nut
employ any person in any manmrw As In become subject o the Wo l m'Compewton -
Lawa of California.Dau
Applicant
NOTICE TO APPLICANT:If,after meting Chun Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Lahor Code,you mum
0z forthwith comply with such provWnns or this permit shall MMemW Invoked.
fp CONSTRUCTION LENDING AGENCY
[+ Ihereby affirm that Chert is a construction lending agency for the perfmmawn of
ai Cho work for whim this permit is Issued(Sec.31197,Civ.Ca
Xl0 lender's Name
in Lender.Address
U Q I certify that 1 have rod this application and sou that the above inform Won is
ty H COMM 1 agree to comply With all city and county oN ossoco end mate laze minting to
0U building crnstrenirn,and hereby authorise MpuMnudivea of thin city an enter upon the
u7
abow-mentioned
re to okeep
property for inspection pua
(W
(Wt)agree
save,indemnify and keep hvmlent the City of Cupertino against
In Iiablliues.judgmeno,costs and expenses which may in any way wean against said City
U`1 in consequence of the granting of this seri(.
r7 APPLICANT UNDE ANDS A D WILL COMPLY WITH ALL NON-POI Issued by: Date
SOU cl B* AT S.
W Y VL /lMai /�b� V Re-roofs
tures A,di on"one
HAZARDOUS SURE Type of Roof
Will the applicant or future building Occupant store m handle boamom material
A
t.'.1HCAfld!t
ented by use Cupertino Municipal Code.Chapter 9.12,and the Btalth and Safety
e,Section 35532(x)? All roofs shall be inspected prior to any roofing material being installed.
�
Will the applicant or future building=open,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hauNom air contaminants u defined by tite Bay Ama Air Quality Management all new materials for.inspection.
❑Yes
(have mW the haamdousmaurlelsrequiremema undcrChapter6.95oftheCalifar•
&SafctyC Sxtlors 25 ,25533uu12553a.lun&c Lhaifth,building
no a rely ho tenant.Not 1 u my ruponeihili y m notify fee occupant of Ne
mgmi me ,h me m m�ntenPerncPmin,ter o up. Signature of Applicant Date
l� All roof coverings to be Class"B"or better
O r or amhonwi asset \ ate