03110040 CITY OF CUPER'1'INO
BUILDING DIVISION PERMIT CONTRACT-0R INk'ORMATION-"a
F.a . .5 w Ss -Su• safe t
BUILDING ADDRESS: PERMIT NO0 3 11 0 0 4 0
q
R'S NAME: PERMIT ISSUE DATE
KENT & PATTY KERNAHAN
11/07/2003
PHONE: SANITARY NO. CONTROL NO.
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MGCH
±o o LICENSED CONTRACTOR'S DECLARATION C] O O O
£we F I lumhy air,,.Thal 1 ant licensed under provisions of Chapter 9 hommeneing Job Description
ztww
o ith Section 70M)) f Division 3 of the Busine.ximl od,stvionsCd Oil my is
'a^ infullforeedyQkffca. ✓" 2`gJ ADD 250 SQ. FT. (KITCHEN REMODEL)
Licence clu Lic.p
e�DDa Corer CONTRACTOR: NORTHSTAR CONSTRUCTION
n PP `7/ ARCHITECTS DE ATION
f W V 1 understand my pIlmr,h dl W used as public rcc uds
s n Licensed Professional
apg OWNER-BUILDER DECLARATION
<S. I hereby notion Nal I am exempt from the Comrac ors License Law tot the
O poi following mason.(Seroma 71131.5.Business and Professions Code:Any city or county
3 m which 2qulrCi a permit to construct,alter.Improv,demolish.or repair any someone
_iy priono its issuance,alsomquires lheapplicatfmrsuch Permit o rile asigned statement
-zea that he is licensed pursuant mthe provisions°f the Contractor'aLiecnscLaw(Chapter 9 Sq. Ft. Floor Area Valu$j�)6795. .
'ems" Commencing with Section 7")of Division 3 of the B dimcm and Professions Codc)or
$ Nat he is exempt du mfrom and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit satccu the applicant to a civil penalty of 311P&5ai15er 0 0 Occupancy
not more than five hundred dollars(SSW). p y Type
❑1,as mune,of the Prefacny,or my employees with wages as theirsolc compensation,
will do the work,and the awnme is not intended or offered for sale(Sec.7041,Business
and Professions Code:Th,Commortr's Lieenu Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided nonsuch improvements scatter intended or offered torula.It. �1�/L'1
however,the building of improvement issold within ter yearof Compiction.the owner- p ��®
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
El I,as owner of the propsny,am exclusively contracting wit licensed contractors to FEB 't
construct the project(Sec.7044.Business and Poofessions Code:)The Convactori Li- . B 1 711004
Anse law docs not apply to an owner of progeny who Wilds or improves thereon.and L
who conmacu for such projects with a comractnr(s)licensed pursuant to the Contractors
Lie1amase Taw. BUILDING
❑I ase exempt under Sec. B&P C for this reason
IData
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following daluations:
have and will maintain a Cro fcau of Consent to self-ins"m for Worker'sCumpen-
,as provided for by Section 37W of the labor Code,for the performance of the
Tot which this permit isissud,
have and will maintain Worker's Comacroltion Insurance,u acquired by Section
of the LaWr Cale,for the pc rmance of the work ror which Nis Permit is issued.
oryts�ptnsatiPlrl.sutlghtt carzicrdWA�N"�ocy no,now"i D
cr/` �' s(/ Po1RY/
CERTIFICATE OF EXEMPr10N 101 ER$v/-00
r/
COMPENSATION INSURANCE T
(This section need not W cmmplcted i(the Permit is for one hundred dollars(f Id))
or lass.)
1 ccnify that in the perrotmantt of the work for which this permit is issucd,1 shall not
employ any person in any manner an as or become subject to the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL alter making this Cenificau of Exemption,you should
become subject to the Worker's Compensation Provisions Of the Labor Code,you must
�z fonhwitoComplyWithsuchprovisionsorthisPermitshallECdeemedrevoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby af0rm that there is a consimction lending agency I'nr the performance of
D: 25the work for which this permit is issucd(Sec.3(197.Civ.C.)
W Q Lender's Name
Da Lenders Address
� z
U O 1 comfy that I have read this application and state tot the above information is
f' comet.l agree to comply with all city and county ordiunces and stale lads relating to
C U building consmaction,and hereby authorize representatiucs Of Nis city to enter upon the
ahovctmemidgm property(an iupcni"n which a
- s.
(We)agree m save.indemnify and keep har.leas the City of Cupertino against
z hatilinconsequence of
uang expermsmit. may in any way acrneagainsuaid City
Uz in consequence of the granting of this Permit.
APPLICANT ER AND ND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
S URGE U A S.
Re-roofs
Stgnamre orA pine. unvacmr Data
HAZARDOUS MATERIALS DISCLOSURE a Type of Roof
Will the applicant or future building occupant stere or handle hnallous material
dcdrv"by the Cu on Municipal Code,Chapter 9.L2.and the Health and Safety
C.Section 25532(1)? +,
❑Yea ❑Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Her?
t]yes KIN.
I have mad the h rand.us
materials requirtmenls under Chip.,6.95 of the Cal ifor-
niaHcalN&Safely CorCSecGu 25505.25533and25 les round ba,dtie Wilding
J<�/ wh u a On ail is my rciportsibrht ptGr� Npc room, t of the
req a n' m ,t poor lnias°,n"nrac -"dy`'rp�"�cy,� Signature of Applicant Date
Owner OfanthOH79nspent //�/ Data
All roof coverings to be Class "B" or better
CITY OF CUPEW11NO �'^
BUILDING DIVISION PERMITgCONTRACTORINFORMATION
au 1LDING ADDRESS: BAY AREA SUNROOMS PERMIT NO 03100040
O`NNER'S NAME: 17 W 41ST AVE PERMIT ISSUE DATE
_,ZONE: (650) 341-6201 SANITARY N0. 6 CONTROL N0.
.ITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECr PLUMB MECH
O o LICENSED CONTRACTOR'S DECLARATION G� O O O
w I hereby affirm Nat 1 am licensed under provisions M Chapter 9(commencing Job Deserlp_tlon
1Z� with Scclian]Il(X) lDivisio�n} 'c Busime' tlPr fcssians C„dc.and my license is p
;qi Itucl` ue.A' y SUNROOM
4y Date Cu for
;Ka I�undmypinsshllkususedaaspublic rec°ds FEB 1 2 2004
ryU
.oF Licensed Pmfcssinnel 10
OWNER-BUILDER DECLARATION �VI�®�pI��
'
<7 1 hereby affirm Nat 1 am exempt from Btu Contractors License Law for the ® G
00 allowing reason.(Section]11]1.5,Business and Professions Code;Any city nr county
i m� which requires a permit to construct,alter,improve,demolish,or repair any structure
'-z in prion,,its issuaoce,a..Lx,uirza th.appliered forsuch permit to rile asigned Stini em
-ss<
that he isfrecused pursuant mtheprovisions(if the Contractor's UcenaeLaw(Chapter 9 Sq. Ft. Floor Area Valuation
iF0 (commencing with Section 7")of Division 3 o the Business and Proressiutu Coll or
`t Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of 31632002 . 00
Section 703 1.5 by any applicant for a permit subjects Nc applicant to a civil penalty of APN Number Occupancy Type
.at mom Nen fire hundred dollars(5500). P Y YP
[ 1,m owner of the property,in my employees will wages res Heir sole compensation,
will do Ne work,and the structure is not intended or offered for sale(See.]Odd.Business 101 - FOUND ��
and Professions Code:The Contractor”License law docs not apply to an owner of Wid Inspections
property who builds or improves thenar.and whuduessoch wart hunneforNrough his 102 - PIERS
own employees,provided that uch improvements ere not intended or offered foreele.It, lO3 - LIFER
however,Ne building or improvement is sold within one year of completion.the owner-
builder ,will ban the burden of Proving Nat he did not Wild or improve for purpose of 104 - REBAR
wlo).
❑I,as owner of 1W property,am exclusively contracting with licensed convectors to 10 5 - ANCHOR BOLTS
comtmm the project(Sec.?I)aa.Business and Protmsfons Code:)The Contractor"Li- 106 — SEWER & WATER
mems law does not apply to an owner or property who Wilds or improv¢themon.and
who contracts for such projects with a crouractor(s)licensed pursuant to Be Contractor:' 202 — UNDERFLOOR PLUMBING
Ll Law. 203 - UNDERFLOOR MECHANICAL
❑Iam
am cacmpt order See ,BhPC for this mss,,'
ata 204 - UNDERFLOOR FRAME
dncr WORKER'S COMPENSATION DECLARADTION 205 - UNDERFLOOR INSULATION
Ithereby aWe.senderperdt,ofp<juryazafthefollowing deaarauam: 301 - ROUGH PLUMBING
Thaw and will morina Certificate of consent to self-insum for workers ComNn- 302 - TUB Se OR SHOWER
n,tee Provided for by Section 37M of the labor Code.for the performance of the 303 - ROUGH MECHANICAL
for which Nie permit is isimed.
1 have and will maintain Workers Compensation Insurance,m required by Section 304 - ROUGH ELECTRICAL
37M of the labor Code.for Nc performance or the k far wh"h Nis permit is issued. 3 O 5 - FRAME
My Worker' ompcmarm InsuCre Came,end Pal r uumb�e=)rLayq'.a V�; 306 - HOEDOWNS
Conic CERTIFICATE OF EXEh1Pr10NYFROMW" ORKERS' ` 3O7 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
es'.)(Tris section need not to completed it the permh is for one hundred dollers(SIIX)) 309 — EXTERIOR LATH
1 certify Nm in We performance or the work for which this Permit is issued.)shall not 310 — INTERIOR LATH
employ any perhos"'any Lou nprky kuS�r,resubject tothe Workers'Compensation 311 - SCRATCH COAT
Lawof California
APPlicam '-i �7- 313 - ROOF NAIL
NOTICE TOA 1 NT:1.Compener ating thisvisionsofI ficale Lishouiod.youcast 501 - FINAL ELECTRICAL ENERGY
you should
become subject y the worker's Compensation provisions of the Ia Wr Code.you mull
rZ forthwith comply with such provisions or Nu permit shall W deemed evoked.
502 - FINAL PLUMBING ENERGY
y CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
Iio,by which
Nat there iised(Sect3097,ding agcrNy to,lW perfonnamc of 504 - FINAL BUILDING ENERGY
]$
be work furwhich Nis p.nnoiss.confume...le Civ.C.)
q Lender:Nam. 505 — FINAL ELECTRICAL
Z tenser:Aaer.rs
;J Q 1 certify Nat I have read Nis application and state Nat the above information is 5 0 6 - GAS TES T
L E-' mouser.1 agree m Comply wits all city sad county ordinances and sum laws elating to 507 - FINAL PLUMBING
Z)U building construction,and hereby authmim mphormulives of this city to enter upon the JINMEC CAL
W abovemcmioncd property for Inspenian purposes.
CL (We)agree to save.indemnify and keep harmless the City of Cup rtino against %_5
jfq liabllitim.judgmcnu.eosts and mpemcs which they in any way acemc against said Ctry NG
,Z in conuquencc it the graining of this permit /7
'-v APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- ISSued bC WORKS•
INT Y: Date
SO�RC LATIOpFJ�I�
ave ,,Avco\tractor 0 �)7 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE D Type of Roof
Will the applicant or future building occupant More or handle haardous material
ar dented by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safny
Calc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will Nc applicant or future building occupant OR,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
1�q,
t hesardous air contaminants ar defined by the Bay Area Air Quality Management all n terials for ins on.
!'a tn?❑Yes CSN.C�I have real Ne ha>aNnusmaterialsreyuiremcntsunderChapterb YSHcaIN A Safety Calc.Sceuruu 25NI5.35533 and 255Jd.1 understood Nat if dtc Wilding
not have a u:naa it u my respermim ity to noufy t ucuPant sf Nc /
irem svc un ctpsio m ssuanccofaCrofSignature ofApplican Datenor sumo n<dag.nt D e All roof coverings to be Class "B"or better