02090182 CITY OF CUPEWI'INO "Moves " -
BUILDING DIVISION PERMIT , CONTRACTOR�INFORMATION
BUIBB/+6ADSt1SELANEY AV K & M DEVELOPMENT INC PERMrrN0.2090182
OINEAf1&ECHOU 1060 WEST HILL CT APPLICAT®gSpe2"-2002
IDNE: 408 253-9787 SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Op LICENSED CONTRACTOR DECLARATION
Zp 1 herby affirm mar'am licensed anter provisions of chapter 9(commencing Job Description
<w with Section With)of Division Jnl'thc Business and Professions Code.and my Bccnm is
CLEAN OUT
Foy in lull Lure and cite I.
a0'l,? License Cla Lie. G
?y F Q Dale r'J u7 Contract., a jr/C
'7 ARC]IITECT'S DECLARATION
¢a I underneml my plans shall be used as Public records
doau
LL�l], Licensed Procadonal
g OWNER-BUILDER DECLARATION
<P 1 hereby affirm that 1 am exempt from the Contractor's License Law Iia the $1500
i
00 bellowing reason.(Section 7031.5.Business and Professions Code:Any city or county
an%� which requires a permit u)construct,alter.improve,demolish,or repair any structure
prior m its issuance,also requires the applicant for such permit to Glc a signed statement
that he is licensed pursuant In the provisions of the Contractors Lice rte Law(Chapter 3611201 62AM Valuation
at (commencing with Section?000)of Division 3 of the llteinca and Professions Cndc)ur
y _ that be is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant r a civil Penalty of
.or moretharms<hundred dollars(MI. 202p- UNDERFLOOR P UMBING Occupancy Type
I,as owner of the printery,or my employees with wages as their sale compensation,
will Jo the work,and the structure,is not intended or offered for sale(Sec. Business — Reus
and Professions Code:The,Conuacmr's License Law dna not apply to as owner of 507 - FINAL &pCCIIODS
property who builds or improves thereon,and who doessuch work himselfor through his
man employees,provided that such improvements are not intended or offered forsale.If,
however,Ne building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sathJ.
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7144,Business and Professions Code:)no Contractor's Li-
cense law Jens not apply to an owner of property who builds or improves Theron,and �,p
who concocts for such projects with a conductorial licensed pursuant to the Contractor's rC�raO,A G6 9m1!•'�
License Law. 1� p P61%.S E
❑1 am exempt under Sec. .B&P C for this rachon
Owner Dare OCT10 ZDOZ
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of Perjury one of the following declarations: t��
'have and will maintain a Ceni ficare of Consent to self insure for Worker's Compcn- BUILDING
canon,ss provided for by Section 37M of the Labor Cale,for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
l'IIXI of the Labor Code,for the performance of the work for which this Permit is ismed,
My Wor�keJr'ss CCoommpentiouon Insurance earn r,gp)f Policy number aa'
Carrier:!/� 'amu/ Policy No.:lS��Z - UL
/^- 4-V PZFW'ATE OFEXEMPTION FROM WORKERS'
,or,<o COMPENSATION INSURANCE
mustu ction need not MmmplcicJ if rhe permit is for one hundred dollars(SH10)
loss.)
1 tinily that in the perfrocame of the work for which this permit is issued,1 shall not
employ any Person in any manner so as to tocume subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,at making this Ceniticar of Exemption,you should
hecome xuhicel to the Worker's Compensation pro"oons to the labor Cale,you must
QO forthwith comply with such provisions or this permit shall M deemed mvnked,
Z h CONSTRUCTION LENDING AGENCY
p 'thrifty affirm Nal there is a comuuction lending agency lin the porformanm of
fx 7 the work for which this permit is issued(Sec.300,Civ.C.)
la1 Q Lender's Name
4. Lender's Address
r7
I:.l Q 1 certifythatI read This application and sura that the above information is
W F correct,I agree In comply
with all city and array natives Of and sum laws relating e
C) UUJ buocermonstruaionand herfor onauthodvcrposeunurivcaof this City to enter upon the
ahovome judgments,
udg d propertyse for inspection purposes.
(We)agree to save,indemnify and keep harmless the Cit of Cupertino
pr, a p r againu
til him incoities,ance of the costsant cxpeneswhich may in any way acamc against sail City
C.l z m cense ANT of UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCCREGU NS.
'71Z Re-roofs
pI CommnorSMAT 7 IAISDISCLOSURE ale Type of Roof
Will the applicant faturehuildi occupamatoneorhandleharudoesmateria'
as derived by the Cape n Muni' Cmle,Chapter 9.12,and the Health and Safety
Crate.Section 25532nd 1
❑Yes ®No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or f`ututure buildingoccapanl use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emir hazardous air contaminants as thWed by the Bay Area Air Quality Management all new materials for inspection.
Dimric19
❑Ycs W,r
1 have mad rbc harerdous maNrials requirements under Chi.95 of the Califor-
It.Health&Safety Gqe.Section.,25505.25,533 and 25534.1 undenvmd that it the building
tees vol currently have a tenant,that it is my responsibility as notify the occupant or the
rcquirtmcroswhich be son priest.iasltance ofa Cenifeote;V r 7 ane. Z Signature of Applicant Date
.gen, Date All roof coverings to be Class "B" or better