04030193 CITY OF CUPERTINO '
TTON
BUILDING DIVISION PF,l�iviii ,a�+�#�LOR IN 'ORMI�
PERMrrNo.04030193
BUILDING s JAMES H SMITH
PEBMrr ISSUE DATE
ER'S NAME:
$ANTD OL NO.
ONE:
BUILDING PERMIT INFO
ARCHIncr/ENGINEER: BLDG ELECT PLUMB MECN
p� pt� � = t�
LICENSED CONTRACTOR'S DECLARATION J Srt[IBtSQn�
m Z " �.sl AIS
io
:WEi
I bemby from that 1 are iicensod under provisions of Ounces,9(commencing
G with gauon votMB of Divislon3ordx Husinusand Pmfcssiortc Coda.and mylicrnuis
�„ in fall force and effect- KITCHEN REMODEL /�(�G
t2 Licenu Clan Lk.t
3-w Dam
Cortumar 2004
ARCHt be Wo DECLARATION
j a< 1 uMmoand my pursuant be rocs a public ranrds 1R BIL®11VG
jaU t�
001 Lianttd Professional
OWNER-BUILDER DECLARATION
i F
1 1 hereby aRnm Nal l am eumpt[mm the Conuacrots License Law I for the
E
80 following lesson.(Sauon 7031.5.Business and Professions Code:Any city ar county
<� which requims a permit to construct,atter,impmw.de.,umb.m lep d,NY+tncmm
y�to Primmiuissuancc.alomquimsOnapplicantforsuchPemittorleasignedsutement g Ft. Floor Area Valuaton
xx<
that he u licensed pur+usnt m the Pmvuiam of the Conaacmr's Lao"Law tattles 9 q
rF$ (eommendng with Section 70M)of Division 3 of NC Business vnd Proftasion¢CaWe)or
t. dirt he is aempt dmmfrom and the bass fm the alleged casmpt, MY violation of �a5.ps�i,�7,�,..1,
Salon 70313 by arty applicant far a Pemit aubjxu N.applicant m a civil penalty of 3 3V_ A\I0gC0 0 Occupancy Type
rias more dun fiw hmWred dollaa(SSOOF
❑L as owner of the PMPMY•or my—PlOyeea with wages u Heb role compensation.
will do Nework.and 0c umaum is not Intended moRcred metric(Sec.7W d.Bio arks Required Inspections
and Prafesuans Code:The Comme cr's IJo:nse Law does not apply to n owner of
property w hn builds m ire prows u s anon,and who dues smh wart himudf or through his
owamoodayas,provided Wt such impmsemenuue nothdanded oroRund for sale.U.
however,one building or improvement is old within arc Year of mmplcdon.Ne owmr-
builder will iron the burden of proving that he did ma bW Id or Improve fm purpose of
sale./).
:1.u owner of the property,am aclusinely conning with Barsed aonuu+an to
conswct the Pmjea(Sec7004.Business and Professions Cl )de: The Cmaacmrs Li-
c.Law docs rat apply m m mums.of pmanY who builds or improve Neroa..and.
who conuans for such proje It nuanoKU. Iiperyed Purs'umto Ne Conuactofs
Lleons,Law, B k P C for Nb reason
1 am enempt under Sa.
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby a(Rm under puW tY of perjury one of the following declarations:
I haveand will mainuina cmup...reonontmsdCinaum farW fte,campcm
adon.as provided far by Section 3700 of the Labor Code.for tht Performance of tM
w for which his permit is issued.
(]I have am will maintain Workch Compensation Insurance,as mquimd by Section
3700 of the labor Code,for Ne performance of the work for which Nis Pr.tt s bouts.
My Workce.Compensation Insunncc o.and Policy number tie:
Uma; Policy No.:
CERTIF5 E OFFXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
frns section reed Out be completed if the permit Is[m ane hundred dollus(SIM)
ar kis.)
1 county,that in the perrormance of to work for which this Permit Is issued.I shall not
employ any person in any turner an as te become subject to the Workers'ComPcosauon
laws of Caliremia.Dam
Applicant
NOTICE M APPLIUMI':If.afu r..kin,this Carlin..N Eaemptim,you should
outcome+.hien to On Wahcr's Compewdon provisions of Ne tabor Code,You most
.,O foMwiis comply with such ptoAms,or Ns permit shall be deemed revoked.
Z N CONSTRUCTION LENDING AGENCY
F. I bomb,affirm Nn Nem is a construction[coding agency for the performance of
y'> the wink far which or Permit is Wood(Sec 3097.Civ C.)
W Lemm's Name
=z Leaden Address
U C) I comity than 1 have turd thu application and sure Nu Nc shove Information is
u.P cmm, I ague or comply with all city and county on i..and sum laws relating N
U Wilding ce)all.to ..imbyauNanmeep harutivcaof this city roomer upon ft
}a abave-mentionod pmany fm inspection purposes.
(•' (We)ag mo u,cave,indemnify and which
harmless the City le Cope= id City
st
r/1 liabilitio.rydgmru.co+uand eapensn which may in mY vraY acttue aganBt aid City
U z In crosequcrue of the grandng of this permit
APPLICANT UNDERSEA S AN ILL COMP Y WRH ALL NON-POINT Issued by: Date
SOUR REGULATION
Re-roofs
Sismo of Applicaraccineracwr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
.� dl the With ,or future boding occupant am or handle Imardous material
I incd by the Cupertino Munidpal Code.Chapter 9.13.and the Health and Safety
i,Section WNW? All roofs shall be inspected prior to any roofing material being installed.
1 oYta No
Will the applicant or future building occupant use equipment or devices which
a roof is installed without first obtaining an inspection,I agree to remove
emit havardo.s air cmaurrin ms as dcOmd by Ik Bay Ars Air Quality Management all new materials for inspection.
District?
(]Yes No
I haw Turd theh M'no\ma dr requimmenuunder Clapter695 of Ne Califor.
mice Health h sdWy Code.Suctions25505.35533 and 35530.1 understand thatiflhe building
data not cmendy haw IranWt i my respomibility m notify adm
f oupant of
requitcmcnuwhichmmhm poor ssuanccofa c"Im.worOecvprnay. Signature of Applicant Date
-22-c
�� . „•,ren ran Date All roof coverings to be Class••B" or better
CITY OF CUPERTINO
BUILDING DIVISION PERMI ,�, sem.; 1+lfe,�r,}, ,,.G;1,,•es.x.Sa ?r, • , $'-
PERMIT N0.04030193
BUILDING ADDRESS: JAMES H SMITH
n PERM]TISSUEDATE
ER'S NAME:
SANITARY OL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
C= l�
iGp LICENSEDCONIRACIOR'S DECLARATION lob Description
:WE I hereby ar0mr Nat 1 me lie med under provisions of Chapter 9(commencing
iZ withScatkm7 WB of Division 3ofda:BusinessandP,of.,jo.Cade.and mylicense is �nL}7
in full to=mail C =L KITCHEN REMODEL VA, B5
License Dass Lia a
Dare corouraminum-
ARCHITECTS DECLARATION AUG aJ 2004
j s 1 understand my Plans shall W used az public records x]
)yU
Licensed Pmfcssional n
•03 OWNER-BUILDER DECLARATION �RB��B"12?ad:f±
1 1 hereby aRl m Nat I am exempt fmm Ne Co"wnols License Law for tic U IILLYN�N VG
p O following mason.(Section 7011.5.Business and Pmrcuions Coder:Any city m County
I which requires a permit to tmwm=L ilmr,impmw,demolish,or.Pilr any$.to.
"zY Psianmiuissuance.ilsurcquirestheapPlianrfonuchpennitm0leasigncdsummcnt S F[.FloorArea Valuation
<•dat W is licensed porous pmvisiov of Ne ConOanmrs License Law(Chapter 9 q
Y1- (Commeuing with Section 7000)of Division 3 of the Businessand Professiape Coss)
i ..
that e a 31-5 b tWrefmm and the aper it thejctst1m alleged putt.Any vii oy Of 3 r9Vpl"u1Mgr0 0 Occupancy Type
Section in aso by airyapplitand fth•perm it subjectsApplicant n.aevil It of
not mom Nan five hundred dollars(55001
c ❑I,azawna of Ne ProP='=Y•anmy wPl%era veldt vageaazthe'v sole cvmpensaden,
will dtthe"d,and the mrm are is r.nimanded Woffered forsale(sec.Tow,Business Required Inspections
and Professions Cod,The Conuacrmes License Law dues not apply to a"owner of
property who builds or impmses thereon and who does such wank himself.through his
own empltyms,provided Nassuch impmwmenu ars notimonded craRcred forsale.If,
however.Ne building an impovement is old within aro year Of Compleuan.t�r-
builder will have the bum.of proving Nat be did not Wild or Improve for of
sale./).
Ila is owner of the progeny,am scluevely ed,,re,ing with licensed conuaclan to
ech m=t the pmjca(Sec 7044,Business and Professions Cade:)The Cw=u &Lf- .
Co.Law does not apply N an owner ofpmpeny who Wilds or improves thercan,and
who mnuacu for such Prokc wi nteman(x)1 dpumuantto Na Conuactots
License law.
❑1 am exempt under sec P C far this pas".
wereDare
WORKER'S COMPENSATION DECLARATION
I hemby a,,m,under pceilty or perjury esti of do following declarations:
1 hew and will milnuin aCvdOcem of Conant m ucif-insure for Waracfa Compcn-
work for which this fpermit
Section 3100 of do Labor Code.fm Ne performance of dm
is issuod. ,
❑1 have and will maintain Wankeri Compewdon Insuran s,as required by Section
37W of the tabor Code,for be perform anonof the work forwhich this Permit Is issued.
My Work,Campensauon mornmce artierand Policy"umber art:
Carrier: Policy Nat
CER BI:A E OF EXFNPf10N FROM WORKERS'
COMPENSATION INSURANCE _
r,a section tied not b,,,,m ,nd Ira,permit is two=hundred dollars(SI00)
or Ica.)
1 eenify Nat in Ne Performance of the,woh for which this permh is issued,l shall not
employ anypcsmm in any manner m as in become whjcet to the Workeri ComPcmadan
Laws of California-Dare
Applicant
NOTICE TO APPLICANT.If.after mating Nis Certificate or EsemPtion,you should
become subject to the wostei s Compensation provisions of Ne Lmm Cod,you must
�Z forthwith comply with such provalom or Na pormiLm.11 W deemed revnlmd.
Z O CONSTRUCTION LENDING AGENCY
F 41 bembyalfirtn Nat dem us coes"Co n lending spun,for the performanm of
5> the work fm which this permit is issued(Sec.3(19'1.Civ.C.)
Ix]aLinda's Name
0. Lcodeis Address
U Q I certify thL I have read this applieadon and sum that Om above infmmadu"Is
U. corms 1 agree m comply with all city and County on i"moss and sum laws relating m
building e) re.in
Inde niyariampmaenile.the
Nis Of memerupon the
r above-mentioned property for inspection purposes
(We)agree m taw,indemnify and kith harmless the City Cupminp against
liabilities.jWgmuu.cau and espcma which may in anY way accrue against said City
V Z in comegocom or Ne granting or this permit
APPLICANT UNDERSTA S AN ILL COMP Y WITH ALL NON-POINT .Issued by: Dale
SOURCE REGULATION
Re-roofs
Sigwu or AppliandConOanar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
III the applam m ran.Wilding occupant care W handle harudaut material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
• Cada.Seem.155320Y7 All roofs shall be inspected prior to any roofing material being installed.
oYet (Nt
If a roof is installed without first obtaining an inspection,I agree to remove
Will the Ipplicant orfumm Wilding arupantucequip lmetordevices which
emit hazardous air contaminants at defmcd by the Bay Area Air Quality Management all new materials for inspection.
DimicO HI t�
Ye N"
1 have road he hvsadonsmameialsm9uimmems undo Chmus&95 Orion Cslifor-
niaHalthg:SeWyCode,Sttdom25505.35533 and 25534.1 understand NazifNe Wilding
doesnot cunerdly hovea¢nae Nat i my respomihility m nodfy the,eccupan'or the
ir,irementawhi=h, I pdar t ssmaveeda eNr=atetracuPan=y. Signature of Applicant Date
22-0
n..L.. ... -s, sere Dane All roof coverings to be Class•'B" or better
• N N �_ _ / 20<,
IS PncA L •
r
1�
DIS+IWAsN£2 D
WASFIEQ
SialK
W/J�SOoSA L
I
I
I
I
I—
I i
n '
t c m Z4a
0 0
o 0 za
c o
c /''�
N
c c o
ix
Q !
SooMsp
L7 -nDo
LA 0
I £ �
9� m
N
-- --