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TY OF CUPERTINO
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BUILDING DIVISION PERMIT
hCONfRACTRINFQACIONar
L:C,':D1NGADDRESS:
PERMIT NO05090072
R'S NAME:
PERMIT ISSUE OATH
LANDO MUHLSTEIN JR.
09/12/2005
E:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLIC MECH
tu 0 l�
LICENSED CONTRACTOR'S DECLARATION
lob Description
licd under prevision of Chapter 9 (commencing
y arm that 1 ammna
1 Wrcbffi
with Section 7001) of Division 3 ofthe Business and Professions Code, sad my license is
I.fellClan erten.
KITCHEN REMODEL, ENLARGE DOOR
License Cleo �"
Dau: Comrsam,
OPENING BETWEEN KIT. & DINING,
ARCHITECTS DECLARATION
1 understand my plans.hall W used as public mc.rds
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afire that 1 am exempt front the Cormamars License law for the
following much. (Section 7031.5, Business and Professions Cade: Any city or county
which mgaima a permit to eonsruct, Jser. Improve. demolish. or repair my t=lure
prior to in issuance, else becomes the Applicant for such Permit to file A signal tumment
that W is licensed pursuant to the provisions.! tic Contractor's Liecnse Law (Chapter 9
Sq. Ft. Floor Area
Valu4t"357
(commencing with Seclion 7") of Divisian 3 ofthe Bminusand Professions Code) or
thm he is exempt thenfrom and the basis for the alleged exemption. Any violation of
AIRN Number
Occupancy Type
Section 7031.5 by any applicant fer a permit subjects the mpImML 10 a civil penalty of
not ream dun Rte hundred dollars (5500),
35617066.00
❑ 1. u orwner of W ryopaty, army employees with wgm u Otehanle compewtlon,
d Inspections
will do thework. and the slNeren Is mninmaded moffered formic (See. 7044, Business
and property and who donouch work his
wh ons Cade: The Conuseee. License 4w don not apply lf rt owner is
Ids
property who batIprovided
roffredthrough
or
l shut moaerad for Well
roorimprovech improvements
ever.
howman
tOs mid wiuwnot eyer of completion,the Owner.
however. the buildingorImprovemcnl4coldwithin rete year of me
the skids or Improvement
hour
Wada MB have the burden of proving that W did not Wld or improve for purpose of
soled.�CF,
pys.I u owner of the property, am exclusively contracting with licensed mnumron in
eolntroq the (Sec. RW, Business and Pmfcuiom Code:) The Counters U.
project
cense Law docs not pply to an owner of property who Wilds or improve thereon, and
who contracts for such projects with a com sctor(s) licensed pursuant to the Conuacrors
License Law.
❑lam Sec ,Bl P C RiPlim. 9.
Dsm
W S M sATiO LARATION
1 homey affirm under penalty of perjury an of the following declarations:
haw and will maintain aCmir,.m.f Consent m ulf-insum far WorkersCumpcn-
aan. m Provided far by Section 3700 of de labor Code. for the performance of the
work for which this permit is insect.
❑ T have and will maintain Workers Compensation Insurance, u required by Section
3700. film Ubor Code, for the perfann om of dm work farwhlch the permit is iaued.
My Workers Compenadon [=ran= artiu and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMP71ON FROM WORKERS'
COMPENSATION INSURANCE
(This action Recd not becompleted iflhe permit Is form= hundred dollars (SHOO)
to Ice)
I certify that in the performance of IW work for which this permit la issued. l shall an,
employ any person in my summer so at in become subject to the Workers' CompemJlon
Laws of California. Data
Appllmnl
NOTICE TO APPUCANr: If, after making this CmiOnle of Exemption, you should
Wcane subjen ro the Workers Cooperstown provisions of the Labor Code, you most
forthwith comply with such provisions at this permit shall be dmmcd revoked.
CONSTRUCTION LENDING AGENCY
I hemby afr m that then is a momucdon leading agency for Out performance of
the work for which this permit is Issued (Sm. 3097. Civ. C.)
Letdees Name
,
Lenders Address
and sem the information is
I certify that 1 have had this Mandl
/
comet 1 qrm ai o. c un
and sum law eint
withallcity and county edihm us su I
building any r up e
and herby mNodve mosey. lvCa of this city a enter upon dte
or
mmmeclion,
shovemeadonad Pto.. for inspection
(We) kma ha the City of Cupenim against
amen to cove, indemnify sad tech hay
and expenses which may in my way atuve against cid City
ju in
judgments, or the granting
in consequence
inconsequence of DERST NDSthis Pertnll.
APP ICA DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dale
SOU C 0
Re -roofs
Type of Roof
/�
Rmaun o App taMCamrsctor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume Wilding oceepmt pore or handle hvxdous materia
u
as defined by the Cupertino Municipal Code, Chapter 9.12. and IM Health and Safely
e. Section 25532(A)7
❑Yes �No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant use equipment or devices which
emli h molous air contaminants as dcnacd by the Bay Asea Air Quality Management
all new materials for inspection.
Dlstrim7 — `o
❑Yea TY`N
I have mad the htmrdtms materials requirements under Chapter 6.95 ofthe Califor.
Calc,Sxdmss255DS.25533md2553C.1undenm ifdte Wilding
nu H&H,
d ham A mnena Nal it is my responsibillly ro notify tad accupml of the
req nt m or m Cery0cateofOm r'
Signature of Applicant Date
/ O
All roof coverings to be Class "B" or better
Ownor
to ....On a ent rete