06040179 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ` CONTRACTOR,ANFORMATION
BUILDING ADDRESS: UP` INO KITCHEN DESIGNS PERMIT"0.06040179
10190 STONYDALE DR
NER'S NAME: PERMIT Mn DAM
SIDENBLAD PAUL J AND KATHL EN10562 S DE ANZA BLV 04/27/2006
PrMNC: SANITARY NO. CONTROL N0.
(408) 257-4900
ARCHn ECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� I�
.00 LICENSED CONTRACTOR'S DECLARATIONIb Description
tit FF 1 hereby aRrm Nat I am licensed urukr provisions of Chapter 9(commencing O 1 P
wiOSecdan 7(C(h fl) van 3a(dm Buvrtea morrafevsium Code.a mylicenneia
+,n mm�mreeanderkct ��(L 7 REMODEL MASTER HALL AND BATH MINOR STRUCTURAL
'"n? LI¢nsc Clus Lk.e
t„ Dam Contractor
e ARCHITECTS DEC ON
C i< 1 understand my plans shall a used u public meards
>yU
e0t�, Licensed Pndcssianal
3OWNER-BUILDER DECLARATION
S 1 hereby alarm Nat I am exempt(rare the Contractors Liec tea Law for the
:EC following recon.(Section 7113 L5,Business and Proicamons Cala:My city or county
m�+ which requires;a permit to canauuct,altar,impraw,demolish,or music any structure $50000
prior 0 its issuance.also meluiresa applicant ror such Permit to fila a signed stammat
< Nam he is licensed puauanttothe pmvisiomofthe ContrutufsUccveLaw(Chap=9 Sq.Ft. Floor Area Valuation
e1- (commencing with Section 700))of Division 3 o On Business and Profcerions Cattle)or -
5 9 Nat he la exempt Overman and Ne buns for the alleged exemption.Any violation of
Section 70315 by ary applicant fa a permit subjecu Nc applicant mo a civil penalty of
not mom Nan Eve hundred dollars($500). Occupancy Occupancy Type
I,umnuofs pmpmy,ormyemploycrswiNaaguuftGmkcmnpenudon,
will an to wank and Ne swctute Is notktermded oraQare l forage(Sec.70th,Business
and P,afeadons Code The Contraction License Law data act apply to an owner of Required Inspection
propeny who builds or impnome Neeson,and whodoessuch wmichimnelfor through his
own ernployace,provided Nat such impmmmass are sort intended troffernal permit,If.
however,the building or impmmmens is mid within arc you of complcdon,the owner-
builder will lune due taro t of Proving Nat W did umt build or improve for purpose of
,akJ.
1,as owner of Nc property,am=elusively contracting with liaised anmctma to
come La the es not appl(Secy
in an owner
of and F,who ns Code:)TW ms themora n J
cense Law docs not apply m an owner of property,who Wilds or int an On Nertme and /
who e Law.for such pmjeeta with aeontrxmrts)licensed Panamint an Ne Cantrxwh
License Law. v�
❑lam=unps undo Stt .B&PCfm Nis reuan
1V Date
WORKERS COMPENSATION DECLARATION -
1 hereby arTum under pevlsy of perjury arc of do fallowing declarations:
I ham and wBl maintain a Carvfmcaa of Caruem in salWasum furWorkers Comped
union,u pmvitled fm by Secdan 370p of Ne labor Code,for Ne perfmamec of the
work for which this permit is Wood.
❑I have and will maintain Workers Compensation Insurance,u mitered by Section
37M a the Labor Cade,far Nc performance art work for which this Permit is issued. '
My Workers//Compensation InGsm'an'ce ca^rrim and Policy number am:p-y�y
Carrier. :11sr}7 - r LCVQ Policy Na.: L77 ` ' T
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(hutsec tiro heed not W completed irate Permit is franc hundred dollars($100) a
nr Icsa)
1 cmdfv Out in the performance of Ne work for which this Permit is issued,l shall not
employ any person in any.gree,an u in become subject to Ne Workcn'Compensation
Law,of California.Data
APPliCmL
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you shumW
became subject W to Walker'.Compensation puovisiona of On Labor Cade.you muss
,J z roMwith comply with such provisions or this permit shall a dam"revoked.
z ► CONSTRUCTION LENDING AGENCY
(-s lhereby affirm Oat them laacnnlanding agency for time performance of
C'
the work(or which this;permit la issuedd(So,(Sec.1097,Civ.C.)
GLanders Name .
]z Landefs Address
U Q 1 conify Nat 1 ass lead this application grad sum Naz to gave information is
IL correct 1 agree W comply with all city and county ordinances and sate laws relating to
U U Wilding Conswction,and hereby authorise remexammaiva 01`013 city to enter upon the
Wshove-mentioned Property for imdo
pecn purpses
o
(We)agree to save,indemnify and kap harmless due City of Cupenino against
iFi VI liabilitica,judgmenta.e=u and ns which may in any way acmue&gains,said City
U'z, A APPLICANT
of the granting of this permit.
^ APPLICANT RSTANDS AND WILL COMPLY WITH ALL NO P01 Issued by: Date Z /G
sOURCE U 0 � 7�
Re-roofs
Signe ApplicaHAZARDO Due
HAZARDOUS MATERIALS occupant
DISCLOSURE Type of Roof
Will the applicant or forum Wilding lCable,
amrc orno t e Health
material
u defined io Ne Cupertino Municipal Coo.CTapkr 9.11.and the HcaIN and Safety
We.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Y= o
' Will Nc applicant or fumm Wilding acupam use equipment or dcvlas which If a roof is installed without firs[obtaining an inspection,I agree to remove
Cook hazardous air mntaminams u dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yca Gtl(u
1 have rain Ne hzsarduns materialsmquimmenta underCapkr Q95 arla Calif..
nu H=Ith&SafemyCade.Sectimu 25505.25533 and!2553 .1 undawsnd Illustrate building
dace not CuhaM a tenN�Nae Il ie my mapanUM1i ity m MIIIY IW aI Pa mOf
require taw chmtmWmes missuanceoIscmufcakofOccup Signature of Applicant Date
a
0 o m arizedagent DataAll roof coverings to be Class "B"or better