04030208 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT �CONTR"ACTOR�INFORMATION ...
BUILDING ADDRESS: PERMIT N0.
JDR CONSTRUCTION CO 04030208
R'S NAME: A PIT ANCA 2T_ PERMIT ISSUE DATE
ONE: AR SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lap LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 Wreby affirm
that I w liansod under provisions of Chapter 9(commencing
ith Sccti ] dDivisian3of NC Businus�^dP-rofcssians Code,andmylicensc is Y x119 r/�11
^�N in full once !Beer. �p C` 2 (-" /
License Cl Lle,a ADD 105 SQ. FT. KITCHEN REMODEL JUL 212004
nfqD ,aro 'oSDECr
d l� hand my I SDECt�t ATION
;oln Li roles nA BUILDING
5 OWNER-BUILDER DECLAIRATfOlq—
so
I hereby amrm deal 1 am exempt from the ConuselaYs License taw for the
,0 following reason. 7031.5,Business and Pmfcssions Codc:Any city or county
K S E which requires a permit to eonuroct,al.n improve.demolish.Or.pair any uruemrc
prior to its issuance,also requires the applicant for such Permit to File a signed statement
L'?< B 6 66
al re is license Pursuant to the provisions of the Contracm/s License Law(Chapter 9 Sq. Ft.Floor Area Valu non
a2s,Q (commcneingwithS on7000)of Division3afthe Busin and PmfessionsCec)of
that he is exempt therefrom and ate bast for the alleged exemption.Any violation of
Section 7031.5 by airy applicant fora permit subjcM the applicanno a civil penalty of 3 2VV er0 0 Occupancy Type
not more than five hundred dollars($500).
❑ 1,as owner of the property.in my employees with wages as their sole compensation.
will do the work and Ne atrueru.is not intended or offered for sok(Sec.7644,Buriress
and Pmfessians Code:The Contractors License law docs trot apply In an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
Own employees.provided Out such improvements are nut intended orolfcmd forsol,IL
however.the building or improvement is sold within one year of completion.the owner. -
Wilder wi6 have the burden of proving that he did not build or improve for Purpose of
salt.).
❑L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7064.Business and Professions Code:)The Contractors Li-
cense law docs not Apply to an owner of property who Wilds of improves thereon,and
who Contracts for such projects with a co use or(s)licensed pursuant to the Convectors
License UW.
❑I sed cumpt under SCC. .B&P C for this wan
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affton under pumtY of perjury one of the fallowing declarations:
lhaas and will for
37M or the
Labor Code,for far Workers Compere
sauan,v provided for by Section 3703 of the labor Code,for to performance of the
work for which this permit is issued.
01,
1 hats and will maintain Workers Compensation losurance,u required by Scction
"I of the labor Code,for the Performance of are work for which this permit is issue.
my,
y Workers Compensation Insurance Cantu and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mus rection nee not becompmed tette Permit is rmanehund.d dollars(SIM)
or less.)
1 eenify On in the Performance of the work for which this Permit t issued.l shall not
cmploy any pcssan t any manncf-seas wrr T Jubjcct to 1M Workcrs'Computation
Laws of Califa`rl O
AP ¢ant
N CE TO cr making this previsions
of tof he Labor
ab Exemption,you should
born comply with
W men
roCoons Or this
ttha Lead rCode,you must
.J z. fo nhmmPly with such provisions or thio permiuhall bodamcd revoked.
ZO CONSTRUCTION LENDING AGENCY
(�. I hereby affirm that them is a construction lending agency for the performance of
a > the work for which this permit is issued(See 3097.civ.C.)
{al A Lender's Name
1 Lenin's Add.
V Q 1 ccnify that 1 lave read this application and slam Nat the awn infomtNun is
U, H Correa 1 agree in comply with all city and county ordinances and stoic laws relating to
pU building construction,and hereby authorise repreuentuives of this city to enter upon the
ahovcmentioncii pmpeny for inspeNon pur)eees
(We)agree to save,indemnify and keep humless the City of Cupertino against
f'i,l liabilitics,judgromm.custs and expenses which may in any way scene agamstsaidCity
C)z APPLICANTCUNDERSTANDS Aof the graming of tNDrmn MPI.34ITH ALL NON-POINT Issued by: Date
W�lOURCEREG
Z3� Re-roofs
m HAZARDOUS MA ISCLOS Date Type of Roof
Will the applicant or future building occupant store or handle hnudous material
az defined by the CupertMume, I Code.Chapter 9.12.and the Health and Safety
C.
Scotian 25s32(a)ino? All roofs shall be inspected prior to any roofing material being installed.
�Yns No
Will the applicant or fumed building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmardcus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
D'uric4 l�"'
❑Yes
1 have read the,nojudous materials requirements under Chapter 695 of the Califor-
nia Health&Safety Code.Stations 25505,25533 and 25534.1 undersand Our ifdc Wilding
does not curtamlY have a tenan4 N my re aihility to nouly the oocupam or the
mquiremcnss tube fres aortic npalea(OccuPaney. Signature of Applicant Date
Arman av a ant e � All roof coverings to be Class "B"or better