05020177 CITY OF CUPERTINO
BUILDING DIVISION PERMIT +�CONTRAC�TORINI+ORMATIQN =;
BUILDING ADDRESS: STEVE PARK 111111,190 5020 177
ERS NAME: PERMIT ISSUE DATE
STEVE PARK
,HONE: SANITARYO. CONTROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
uo0 LICENSED CONrRACTOR'3 DECLARATION
F I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing Job Description
Ky
with Section IBM).(DNisian 3 of the Buaineasa^d Praressin.,Codc,md my license is
'e la imfull Once and effect. ADD 250 ' (BED/BATH) /KITCHEN REMODEL
z License Clan Lie.4
Date Cmrtranmr
ARCHITECTS DECLARATION
K I understand my plans shall he used as public mmrds
J s,
3 u0 G Licensed Professional
3 OWNER-BUILDER DECLARATION
<� 1 hereby affirm that 1 am exempt from tiro Convacsors License law for Ila;
00 following mason.(Section)IA I.S.Business and Profc sion Cade:Any city or county
K$fs which requires a permit in construct,alcor,improve,demolish,or repair any stmnurt nnn
�'^ prior m is issuance.also mquires the applicant for such Permit Glc aligned statement
t�'< Inas he pursuant is licensed pursuano Ne pnsvisiom of the Contractors Law w(Chapter9 Sq.Ft. Floor Area Valua[lon
p~$ (canmencingwon Section 7")of Division 3 of Re Business and Profusion Coded or
_ that he is exempt shemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for•Permit ubjecs the applicant to a civil penalty of 3669TRIttlierO 0 Occupancy Type
not mom than five hundred dallan(S3W).
❑i,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the swmure is not intended or offered for ale(Sec.7044,Business
and Professions Cade:The Conuectors License Law dam net apply m in Owner of - Required Inspections
progeny who Wilds or improves thereon,and whodoes such work himself or Nmugh his
Own employcu.provided deal such improvements am nor Intended oroffered formle.If,
however,me building or improvement is old within one year of completion.one owner-
builder will have one burden of proving that M did not Wild or improve for purpose of
ale).
❑1.as owner of the property,am emlusively contracting with licensed cumrutors to
construct the project(sec.7044.Business and Profnsian Cade:)The Contractors U. rr��
cense law does not apply to an Owner of properly who W /J/h Rds or Improves themon,and /r
who convects for such projects with a comnnor(s)licensed pursuant to dm Consracsor's /l a {f p
Creole Law. 1
❑lam eacmpl under$ee. .BkPC for Nis rtuon `•-J I/�\/IW\'
er Date
WORKER'S COMPENSATION DECLARATION
I hereby aRtm under penalty of perjury am of Be,following declarations
❑I hamand will maintains CCNGcate of0macro oself-insure for Workers Compere - 1
anion,as provided for by Section 3700 of the Labor Code,for the performance of 0¢ - y
work for which this permit is issued. •f r iZ;�
1 have and will maintain Workers Compensation Insurance,as required by Section y Cf
( `e
C3137of the labor Cock,for the performance of dee work for which Nis permit is issned.
My Workers C^mpemation Insurance canis and Policy number arc:
Gooier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section reed not he completed if the permit is far one hundred dollars(SIM)
less.)
I cenify that in the performance of the work for which this Permit is issued.1 shall not
employ any person in any manner an atm become Subject o the Workcti Compensation
Laws Of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenificate Or Exemption,you should
become subject in the Workers Compensation provisions of Use ISMer Code,you maul
�z roMwoh Comply with such provisions or Nis permit shall he deemed revoked.
z� CONSTRUCTION LENDING AGENCY
PI hereby affirm that Nem is a conswction Lending agency for the Performance of
cd 7 dm work for which this permit h issued(Sec.3041,Civ.C.)
lt7^n- Lender's Name
z Lender's Address
U Q 1 cenify that 1 have read this application and sure LOU the above infomnauon is
U. F' COMCL I agree to comply with all city and county Gromances and sure laws rdaning to
0O building construction,and hereby auNonze mpmamtins or this city to enter upon the
Y'U abovcme^mooed property for irs,cuan purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupertino agvns
F" y
Liabilities,judgments.toss and expenses which may in any way accrue against said City
r,z, in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Si,..,..of ApplicaDData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tWapplicantor fMuni building CooccupapWwcor and hvudauamamrial
dcfinetl by Nc Cupertino Municipal GOdC.Chapter 9.@,roti the Health mtl Sarcty
c.Section 23532(x)? All roofs shall be inspected prior to any roofing material being installed.
�Ycs ON.
Will the applicant or future building occupant use equipment ordevicea which If a roof is installed without first obtaining an inspection,I agree to remove
cats harafdems air canumirims u defined by the Bay Arta Air Quality Management all new materials for inspection.
Dinria?
Oyes ONO
I have mail the haardousmaNrials requirements under Chapter 6.95 of the Califor.
nia Heal"SafctyCade.Sections 35505.25533 and]55N.1 undcrssml don ifthe Wilding
does not Currently have•Lemon,Out it is my respomihility In notify one occupant or the
requirements which must be mel prior to hams or a CerugemC of Occupancy. Signature of Applicant Date
Owner Or mmorived agent Dare All roof coverings to be Class "B"or better
fi