04050155 77
CITY OF CUPERTINO . 'I
BUILDING DIVISION PERMIT (CONTRACTOR IN.E'ORMATION
BU ILDINGADDRESS: PERMITNO
04050155
OWNER'S NAME: PERMIT L55[IE DATE
ASk
12
JE:
SANITARY OL NO.
ARC HITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
yzz LICENSED CONTRACTOR'S DECLARATION
y F 1 hereby affirm Nei 1 am licensed under previsions of Chapter 9(commencing Job Description
aZyGj with Sttrmian efefDivision]of me Busi,gv ane Profcuinnacodc,ane my license is
n full force ane erred.
Liaenm close L;ek ADD 527 SQ. FT. /REMODEL
_W Dam Camaral.r KITCHEN/CRAFT RM/DINNING RM
ARCHITECTS DECLARATION
as
a 1 understand my plans shall W used as public records
as
OyU
3 so Licensed Professional
a.pa OWNER-BUILDER DECLARATION x\
.a 1 hereby eflirm that I am exempt from the Contractors License Law for the JC
aro
p O following reason. oto,t ]IBIS Business and Professions Code:Any sty or county
ac—at at which myuircs a pmmit to enswn,alter,improve,h Perlia m e pair any.tatunmt
�iy prions its issuance,also the me aisions.(,hecant for sucContrarmluo filcasigned statement
C a thmhcisliccnseJpursuanuothcpmvisionsnRhcContracmr'',LicenseLaw(Chapter9 Sq.F[. Floor Area Valuation
,,FD (cam mtncing with Secban7")ofDivision 3 of the Business and Professions Code)or
y Nat he is exempt themfmm and me basis for the alleged exemption.Any violation of Inoonn
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more man five hundred dollars(S500).
❑1.az owner or the pmperty,or my employee with wages u their sole compensation,
will do the work.and me structure is not intended or offeree for sale(Sea.706.Business 35701040 . 00
and Pmfcssions Cede;Tim Conmetor's License Law does net apply to an ow,mt of Required Inspections
property who builds.,improves Neaten,and who dom u It work himaelfermmugh his
own employees,provided that such improvements arc not intended or offered for sale.If.
however,the building or impare.t is sold within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
salt.). -
1 'I,as owner of the property,am exclusively Contracting with licensed contractors to
cto cos the project(Sec.7060.Business and Professions Code:)The Convarem's Li.
nice few docs not apply m an owner or property who Wilds or improves themon,and
who contracts for such projects with a eontaclor(s)licensed pursuant tome Contactors
License Law.
I.exempt er Sec. .B&P C far this..an
Owner �I [yam, Data 3
\ RKER'S COhay E ISATION DECLARATION
I hereby affirm under penalty a perjury one of g declarations:
have and will maintain aCera ficae of Consent to self-broom for Worker's Carso
n,as provided for by Section 37W of the Labor Code,for the perfortnanct of the
work far which his permit is issuce.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the pcdmmance of the work fur which this permit is issued.
My Worker's Compensation Inaunna carrier,and Policy numhcr ae:
Cartier: Policy Ne.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is(mane hundred dollars(SIN)) 4
or less.)
1 certify Nat in the raformouse of the work for which this permit is issued,1 shall nut
employ any person in any manner so as m become subject 10 the Workers'Compensation
Laws or California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject t.the Worker a Compensation provisions of the Labor Code.you must
Z forthwith comply with such provisions or Nis permit shall be deemed evoked.
Z O CONSTRUCTION LENDING AGENCY
[-. `G I hereby affirm that there is a construction lending agency for the perfurmanat of
pa.> the work for which this Permit is issued(Sec.3097.Civ,C.)
W QLenders Name
0. Lenders Address
U C) 1 certify that l have read Nis applicaion and sum that the above information is
Uy F comet.1 agree to comply with all city and County ordinanms and scam laws relating to
0 building conswction.and hereby authorize representatives of this city to enter upon the
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above mentioned property for inspection pathoses.
F G (We)agree an mve,indemnify and keep harmless Ne City of Cupenine,against
N liabilities,judgments,costs and expenses which may in any way access against said City
U Z in consequence of the granting of this permit.
^' RCCA LDE �DS AN p WILL COMPLY WITH ALL�NO O�INT Issued by: Dale
SOURCE R NATIONS. a/]/a'l WILL
r/
Re-roofs
Si mac.f Ap nt/Conlract Dam
g �AZARD MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building occupant store or handle haraMous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and me Health and Safety
code.Sebe.25532aYs All roofs shall be inspected prior to an roofingmaterial beinginstalled.❑ves
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
? J
Yes y0 No
I have mad the hazardous materials eyuircmenLa under Chapter 6.95 of ret Califon
ria Health&Safety Code,Said..25505,25533 and 25536.1 understand in.if the building
docs not currently haw a grant,mat it is my responsibility a notify Nt o:cupant of the
reyulreme which mus Wmct ar uroatencc of a Cmtificam of atupa.ar Signature of Applicant Date /
carer ar a m ri..ea agent Date i All roof coverings to be Class "B"or better