04010014 CITY OF CUPEWFINO
BUILDING DIVISION PERMIT CONTRAC=TOR INFORMATION:,„
BUILDING ADDRESS: 11111N'04010014
ERMITNOO4010014
NER'S NAME: PERMIT ISSUE DATE
MARY J & RUSSELLGUNDERq0
10 ONE: SANITARY NO: CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRd under provisions
DECLARATION
d thereby.roanthat ivislamIiceucdunderndPrtonsorChaprer9mylieconeis Job Description
Zj iu with ScorceanW7uf Divigion3of the Business and Profcssiuna Code.and myliccvcis
m ran force and effect.
;'q= LicenseClaa Lieu KITCHEN REMODEL/CLOSET UPGRADE
'go DOW Contractor
qq ARCHITECTS DECLARATION
WU 1 uMelsund my pbria.hall k used az public Mo.,&
u.a fees Licensed Professional
OWNER-BUILDER DECLARATION
.a- 1 hereby affirm that 1 am exempt from un,Contractor's License Law for the
i00 fallowing mazon.(Section 7(n 1.5.Business and Profc iota Code:Any city or county
in B( which requires a Permit to construct,eller,Improve,demolish,at repair any structure
nno
_ZT poor to its issuance.also mt,uims the applicant for such perm it to Glc a signed.vatomcnl
ESG that he is licensed ruminant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
rat- (commencing with Section Division Sof the Busineas and Professions Code)or
i 5e$ Nat he is emmpt therefrom and the base for ole alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit Objects flue Applicant.o a Civil Penally of 3�19i6Q1u'13'BerO 0 Occupancy
not more than the hundred dollars(5500). pane y Type
❑1,u owner of the pmlx'+ty,or my employe.wish wages u tkir sole c=Mnudon.
will do the work,and the strontium is not intended croffered for sale(Sec.7Daa,Business
and Professions ewe:Tk Contractor,uattae law does not apply to an uwrcr or Required Inspections
properly who builds or improves mercon,antl who does such work himselfor through his
own employees,provided that such impmsemenu are not intended or offered foraale.If.
however.the building orimprovementismld withinone year ofmprovefortheowner-
h leer will have the burden ro proving Nu k did not Wild m improve for thepurposeOwn of
r-
sal.). 1 /
h a owner of me property,am exclusively contracting with licensed contractors to
.rivet the pmjca(Sec.70ad.Business and Professions Code:)The Contractor's Li.
testae law docs not apply loan owner of property who Wilds or improves thereon,and /
who contracts for such projects with a contractor(s)licensee pursuant to the Contractor's
License law. /
❑I am ex said under cc. B k P C f this reason /
kat(' X— 'r�'.+ ��pQ}y� �0 O f Z
\WO ER'S COMPENSATION DECLARAatpN - n
1 hereby aRmt under penapy of perjury ore of the(dd(flowing declarations:
I has and will maintain a Ceniftmm of Cansenl to self-insure for Worker's Compsn.
salion,u provided for by Section 37M of the Labor Cwe,for the performance of the
weak for which this permit is issued.
❑1 have and will maintain We Compensation Insurance a Icyuired by Section
3700 of the labor Cwc.for the performance of Ne work for which this Permit is issued '
My Worker's Compensation Insurance Cartier and Policy number art:
Cartier. Policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThH seninn need not kcompletcd If the permit ll!.lore hundred doll¢nIOD)
M ICS.)
I ccnify that,in the performance of the work for which this permit is ii seed,1 shall not
employ any person in any manner sit as w become subject to the Workers'Compeuation .
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the worker a Compensation provisions of the Labor Code,you must
.JO forthwith comply with such perwisime,or this permit hall he deemed revoked.
'z pjy CONSTRUCTION LENDING AGENCY
'r+ I hereby affirm that there is a commictun lending agency for performance of
C' the work for which this permit is issued(Sec.3097,ON,C.)
Saint,
0 Lender's Na
4'
az Leaecr's ess Addr
U Q I CCIMe Btal I have Rad All
City Add county
and Stale Ordinances
NC above ws Mintiing IS
C U torten.1 o me to comply with all city and county oNtives of and sum laws Minting m
C U Wove-me0uuuction.ane herebyauthon p representatives of Nu city to enter upon tk
akvetmcnuonw property for inspection purposes
F 1 (We)agree to save,indcmni fy and keep harmless the City of Cupertino against
h tootetle.ersom rda,Coming expeueswMcM1 may in any way acerae against aid City
(J z APPLI ANT NDERranVDS this permit.
^ APPLICANT UNDERSi OS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S RCE REG TION
U Re-roofs
�Rtraft.oa ate
HAZARDOUS MATERIALS DISCLMU Type of Roof
Will the applicant or future building occupant store or handle haarduus material
az defiled by the Culifinu Municipal C .Chapter 9.13,and he Health and Safety
e.Section 355320)?
[3 Yes All roofs shall be inspected prior to any roofing material being installed.
Will mea applicant future building occupant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
nn s p a it Qu rat Mang which g
it hasardnus Cir contaminants az dcbncJ by the Bay Arca Air Quality Management all new materials for inspection.
uicl? /
❑Yes t�
1 have mad me hanoh usma erials requirements under Chapmrfi.95 office C.lifor
nu Food"SAMIYCwe.Seetieau 25505.35533 Aral l undcrsmM than difc Wilding
dors not currently have a tenW 1.fit it u my mspouihilitY to Iwtify tk occupant nT Ne
RyuT mcntswni ,lkdlcl Pd9r iauacertineato.ramlcuri ` �` Signature of Applicant Date / /
wncruraulh ` dagent Date - All roof coverings to be Class "B"or better V