04100058 CITY OF CUPERTINO �m '�'``•�'�' '�" ''F'"rc' � h
BUILDING DIVISION PERMIT CON,TI2AC" t)�2 TNMATTOIV•
BUILDING ADDRESS: PERMIT NO.
K & M DEVELOPMENT INC 04100058
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY qftOL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
eLoc O PLUMBO O
3 p LICENSED CONTRACTOR'S DECLARATION
tui 1 heroby affirm I I.I am Ikenacd under provisions of Chapter 9(commencing lob DESCTipt10 ���
whh Section 7IXNB of Dlviaton3ofthc Businessarced Pro(eWon Code. rad mylicenseu
wren rents and ercectes ueg ,¢I �+ /� SFDWL-2 STORY (4079 ' LIVING
License
Dem n ` ARCHITECT'S DLARA ON
LED
ARAGE 880 SQ. FT. �� a� ds
I underwnJ my plan shall W used u public records
C Licensed ProfcadetAl
y OWNER-BUILDER DECLARATION
I hcrehy affirm that 1 am exempt from the Communes License law for the
p o following mason.(Section 753 L5,Business and Prolewshus Code:Any city of county
$(L which requires a pmmit to construct,altar.bnpm n.demnlntb,or repair any mecture
�n prior tilts issuance,aim requims the applicant forsueh permit in 01 cu1ineNatatement
�< That M H licensed pursuant to the provision of the Conuxmr'Wanse law(CMper9 Sq.Ft.Floor Area Valuation
5? (commencing with Session 7000)of Division J of the Businessaed Professions Cade)or
.. That he is esempl therefrom and the bull for the alleged exemption.Any violation of
Section 7031.5 by any appiksot for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not mom than Bve hundred dollars 3!100).
❑1,As owner of tW property,or my employees with wages As their sell compensation,
will do the work.and the structure is not lnundesd or offered for Axis(Sec.7064,Business 36204006 . 00 Required Inspections
and Profeski.Cod,:The Conuacmfs Lune Law does not apply he an owner of q P
property who builds or Improves thereon,and who does such work himself or through his
own employes,provided that such Improvements are not Intended oeoRend for sok.If.
however,the building or Improvement Is mid within one year of amplclaa,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
.to).
I,as owner of the property,are exclusively contracting with licensed mnuutan m
construct the project(Sec.7044,Business and Profession Cade:)The Contractor's LI-
ane law does not apply in an owner of property who Wilds or Improve thereon.and,
who contracts(or ouch projects with a contractor(s)licensed pursuant in the Conwarm's -
Lkense Law.
❑l am exempt under Sec. ,B k P C for this rason
Owner Data
WORKER'S COMPENSATION DECURATTON
I why aaosn urWer penalty of perjury orc of the following declantons:
I tum and will maintain•CeNbcau of Consent to self-Injure for Warlaes Compo-
saton,as provided for by Section 3700 of the labor Cade.for the performance of the
work for which this permnt is island.
❑1 have and will maintain Woekces Compensation Impotnce.u required by Section
31M.1'the Labor Code,for the performaann�ce of the work for which this Permit Is issued.
My worker's CeMePr �"�wt �`�/ PoIIon luxuriance carrier �cy Nliary number tie: _
CERTIFICATE OF EMPI70N FROMf'WORIRKERZSf%O '
COMPENSATION INSURANCE
front secnion need not he completed lithe permit Is foroachundred doRan($100)
nr toed
I terrify that in the performance of the work for which this permit is!wood,I shall not
employ any person in any manner an As in becomembject to the Worked Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Carolinian of Exemption,you should
Weems Subject In the Warkm'a Compensation provisions of the labor Code.you muss
,J O forthwith comply with inch provisions or this permit Mail be deemed rewind.
v~IZIi CONSTRUCTION LENDING AGENCY
(n I hereby affirm that them is Cgntructna lending agency for the performance of
the work for which this permit is issued(Sec.3097.Civ.C.)
Q Lenders New.
=z Lendets Address
6J Q 1 eenHy that I have read this application and Stam that the above Infomutioe ts
Uy camocL l grte in comply with all city and county ardinnm and sum laws relating to
O rV^ building convection.and hereby mthories representatives alibis city At enter upon the
W above-mentioned pmpeny for Inspection purpuea
C (We)agree in save,indemnify and Is,p harmisw the City or Cupenino against
rA liabilities,judgments,cru and eapmues which may in my way acmm against said City
L)7 In consequence of Ne granting of this permit.
F-h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL&ONS
Re-roofs
mUS MATERIALS DISCLOSURE Type of Roof
WlliNeape building aecupant slam or handle hawrdous material
As
defined by time Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Secuan 25531()7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes a
Will the applicant or runt.Wilding occupmt use equlpmmt w el which If a roof is installed without first obtaining an inspection,I agree to remove
ItmaMnus air conumin.nmy u�Wined by the Bay Area Air Quality Management all new materials for inspection.
❑J�J
❑Yea N
Ileew revel the huardws moor!ab require menu under Chapter 6.95 of me Gl iron
nil Healhh&Safety Cade,3ecdons25505,25533and25534.1undcnwAth iftin Wilding
doesnor curmndy haw a wrote,mar it is my raponibility m notify do occupant n(thc
requirements * .m met poor in can C,mnam or occ pansy. Signature of Applicant Date
$fa aS
era Dam All roof coverings to be Class"13"or better
G