05010006 CITY
DING DIVISION
- PERMIT CONTRACTOsa.R INFORMATION -
°
BUILDINGADDRESS: IKB INC PERMIT N%5010006
11129' CLARKSTON AV
OWNER'S NAME: PERMIT ISSUE DATE
WILLIAM & JUDY WILSON 346 MAIN ST 01/03/2005
E:
SANITARY NO. - CONTROL NO.
(650) 941-4384
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION .•
UW g1 hereby affirm that I son licensed under provisions of aspect 9(Commencing lob Description
wires etion 7tXq)af Divixion3 Drum Busineu andP or 4i s code.andmylicenscis
imrmum a arreot. /n 1773 REMODEL MEIDA &' LAUNDRY RM
Z�z Liccnu ✓ Lib.N - - ... . ..
't H Dam /�3'lQ1�Con_.1C A _
yyty ^�\�� As,ladl CTSOECbli.mcmts�
Yya y� I undcmunJ my plans¢hall W tired as Public rtcmas -
�6D ,
3 u t-, Licensed Professional
OWNER-BUILDER DECLARATION
x003 1 heathy alarm that 1 1. exempt Imre the lessors Co License c law for the _
whichfollowing re,un.St permit t 71DL6.Buinus and improve,
demolish.
Code:Any city or County
F.
m� which its hun a permit n u ma dhe alms Imprrve,dcermit t fi repair any etruaue, $42000
FIy prlarmlLLcennod e,alW mllal feta theapplicart softec Wehpetoil sou a Law(Clo torr?
< (CommBcetsudpa"suan7")o(vismunrmecanuactsnuarselaonsCocuv9 Sq.Ft. Floor Area . Valuation
X H$ dust hes exampth en,fr n s and basisdf r th the Busalleged
cv and Proon.Any
Codc)or -
.. Nat he u exempt thcrt(rom and the bazis for the ellegrA exemption.Any violation of
Section 7031.5 by a"applicant for a permit subjects the applicant to a civil penalty of _ . .. C QCCUpanCY'TYPe
not mom Nan Eve hundred dollars(M).
❑I,uawtur of the ProPmty.amy employee with wguaz their sole rompensstion. -.,
will do Ne work and the swcture is not intended oroffemd forsale(See.7044,Business _
Required Inspections
and Professions Cade:The Contractor's Limme,law does not apply ts an owner of - -
pmpeny who Wilds or improves thereon,and who doessuchwork himselfor through his - -
own employees,provided that such improvements art not inunded oroRemd tarsale.If. n/1
however,the building or improvement is sold within one you ofcompleuon.the owner- /) -
builderwill have the burtlen of proving Net W tlitl not Wild of improve for purpose of
1,asowner of the property,am exclusively canbxting with licensed cantrtwm
s
co surae,the project(Sec.7044,Business and Ro(estiou Code:)The Contracts".Li.
terse law does not apply to in owner of property who Wilds or improves thereon,and _. _. ... .__.
Fir-
who contracts for such prodecuw NowatrotoKs)littmedpursuantwft Contactoh - - - - • --,
License law. ❑❑
❑lam exempt B h P C for this maven
caner �u � 7 - -__ �_ �.'r.•��Y.1` !,`�.�4�
WORKER'SCOMPENSATIONDECLARATION,
1 hereby affirm under penalty of perjusy arc of the following declarations: II 11 4v -
Ibeveand will maintain aCeniBeteofCenters tsulf-insure fa.Workdr's Compcnc.
ration,az provided for by Section 37M of the Labor Code.for the Performance of the -
workforwhichthispennitisissued. -
❑1 have and will maintain Waken Compensation Inau Berm,az naPdred by Section .. .. -
37M of the Labor Code,for the performance of the work for which this permit is issued.
My Work els Compensation insurance carrier and Policy number art:
Policy No,
CERTIFICATEOFEXEMPIONFR RKERS'
COMPENSATION INSURANCE
(Thissecuon Oman.,Wcompluod ifthe Permit is Inform hundred Call.($300) -
oflCsa)
1 ttnify Nat in the performance of the work for which this Permit is issued.I shall nut
employ any person in any manner Boaz of become subject to the Worker:Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this Ccmificau of Exemption,you should
become subject ts the Wmrkeis Compensation provisions of the labor Code.you most
.J O forthwith comply with such provisions lir this permit shall W deemed revoked. ----
ZV) CONSTRUCTION LENDING AGENCY
(.. Iherebyafirm Nm dere iso costswctinm lmndingagency for the Performantt of
C the work fur which this permit is issued(See.3097,Civ.C.) - ...
Lal Q Lenders Name
z Lender's Address t
U C) I car ify that I have road this application and sone that dm aW vet infom,ation is
IL P come,.1 agree w comply with all city and county ontinantts and suite laws misting to
0 U building convection,and hereby authome rePrescnutiva of this city to enter upon dtc
4S1 ahove.mentionca pmpeny for inspection purposes.
(We)agree to save,indemnify and keep harmless the City or Cupertino against
F" h Iiabilitiu,pdgmsu cnts,crss andespenwhich may in anyway...againstsvd City
U Z APPLICANTnxqucncCUNDERSTANDSof the granting ofthis AND WILL COMPLY WITH ALL NON-POINT Issued by: Dace
SOURCE REGULATIONS.
Re-roofs
Sig alum of ApplicanaConuactsr Dau Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the aPPlicant oar future Wilding..Pa.,amrc or handl=haarduus maurial
as defined by the Cupertino Municipal Cade.Chapter 9.11,and the Health and Safety
otic.Semon 25532(a)7 All roofs shall be inspected prior to an roofing material being installed.
❑Yee fa7Na P P Y g g .
Will the applicant of future building«=spam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haamous air comominand as dCBncd by the Bay Arta Air Quality Management all new materials for inspection.
DisuicA /
❑Yes GNo
I have mal the ha ardrus mamrialsmyoitemene under Chapur 6.95 of tFe Cable,
Iia Ncal"Safcty Cotic.Secuas255C5.25533 and 25534.I.Sule sund tha iftle Wilding
ones non Currently have aT is my responsibility to notify the o¢upant of Ne
mcluimmcnu which me a nonoisouaMe ora Ccmrca or pC ppn Signature of Applicant Date
owns >amasivedaseof Date All roof coverings to be Class t'B"or better