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BUILDING ADDRESS: PERMIT NO.
CAROL OZAKI/BARRY WHALL 04070200
OWNER'S NAME: PERMIT 15513E DATE
DONE: SANITARY OL NO.
ARCI{ITBCT/ENGINEER: �? - BUILDING PERMIT INFO
BLDG [LECs PLUMB MECH
uecZ, LICENSED CONTRACTOR'S DECLARATION MALE
Oo ]0�1Wl 1 0 ��®
❑❑ 1 heathy affirm Not 1 am licensed under provisions of Chapter 9(commencing l�]'°t L1
iWwith Section7dM))nfpivision]of the BusinusanJ Prufcssinns C.Jc.and my liccnuia '
'a« in mu kraanderrC°' KITCHEN REMODEL
j rj i License Class Lie.a
nice Oate C.rTSDECLARATION
OAF �OVY
Y ARCHITECTS DECLARATION
Y < I undcrsmnd my plans shall be used as public records
DyU
3 Licensed botchy ectal I� I� 11 ®� /��
las OWNER-BUILDER DECLARATION Ii IyV�A F({'VVlyl 11111 (\/{\��—%J
0 1 botchy affirm on 1 am exempt from me Conon Co e:Any c Law for the
ao followingreason.a(Section7 construct,
Business and Professions Cade:Any city tarcountyroCom
K m which requires im a permit to vires W alter.improve for such
h permit
repair any.tatemen
w—'^ Cl a in n
prior to its issmncc,also requires the applicant for such permiuo Rkasigned statement
tr< that he is licensed pursuant to Cher provision none Contractors License law(Chapter9 Sy.FL Floor Area Valuation
(commencing with Section 10M)of Division 3 of me Business and Profs¢inns Code)or
n 5 that he is exempt mcrefrom and the basis for me alleged cumption.Any violation of ,�,p�i.�f,� ,{�
Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of 3 2 tl`J3 V'�7er0 0 Occupancy Type
not more than five hundred dollarsWOOL
❑I,az owner of the propeny,or my employes with wages as their Is compensation.
willdothcwor,.and thcswnurt is notimcndcd oroRaed for xak(Sec.7Obd,Business Required Inspections
and Professions code:The Conoactor's License Law docs not apply to an owner of y p
progeny who builds or improves thereon,and who don such work himself or through his
own employees,provided that such improvements are our intended or offered for sale If.
however,the building or improvement is sold within one year of completion,the owner
builder will ha.e the burden of proving that W did not Wild or improve for purpose of
sok.).
❑1,axer of the property,am exclusively contrmning with licensed summers to
,,most mepri(See.7W,Business and Profe sinus Code:)The Contraemr's U-
cense Law dors not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a conwoogs)licensed pursuant to the Contracmrs
L/c nu Uw.
❑lam exempt _.0&PC Ter this cazon
OwnG[ - A. '•1 •l. .
WORK ER'SC ENSATION D[!CIARgTDate\ION
✓// 1 heroby afrmo under pen ty of perjury one of the f Il1ow,R�dalantions:
1 nave and will maintain a Ccd ricam of Consent to sort insure for Worker's Compcm
cation,as provided for by Section 3700 of the Labor Code,for the po fommince of the
work for which this permit is issued.
C3 I have and will maintain Worker's Compensation Inmrance,az required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued
My Worker's Com perstoon lnmmince carrier and Policy number art:
Carver: Policy No.:
CATE
CERTIFIOF E%WMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is Retire hundred dollars(SIM)
icss.)
1 certify that in the psuftemano,of the work for which this permit is issued.1 shall net
employ anya��q,r�any...or to subjmum the Workeri Compensation
Laws of Calirourra.
/
NOTIC T APPLICANT:If,aU yy akin,this Cor iBcatc of Eacmption,you should
become )ca so the Worker's Confp:nsmion Provisions of the Libor Cnde,you must
z'foMw or,
with such provisions or this Permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm thatthere is aconsmoctinn lending agency for the Performance of
!� the work for which this permit is issued(Sec 3097,Civ.C.)
W Q Lender's Name
G Lcnderi Address
VQ 1 certify that 1 have read Nis application and sate Net Ne above information is
(y F corrcn.1 agree to comply with all city and county ordinances and stars laws totaling to
0 building consuuetion,and hereby authorize represcoativcs of Nis city to enter upon the
r above-memiooed property far inspeNon purpomk
(We)agree to save,indemnify and keep harmless the City tar Cupertino against s
F' lodulides,judgmmes.Costs and expome,which may in any waymeme against said City
V z In eonucomee of the,rantin,of this pimi Date
'—'
APPLICANT UNDERSTANDS A W1 COMPLY WITH ALL NON DINT Issued by:
SOURCE RFU :LopS /
/// /• ' CSI' Re-roofs
Date -
HAZARctcts'�SMATERIALS DISCLOSURE Type of Roof
Will the applieamor r ambuilding occupantstom rehandle hazardous matenal
az defined by the Cupenino Munw,p9I Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)] (�^9/ All roofs shall be inspected prior to any roofing material being installed.
❑Yn
win mea licantor future Wildin t sae a torment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
PP Eby thea y p
emit hazardous air contaminants az Jclincd by the Day Arca Air Quality Management all new materials for inspection.
District?
D Yea Nu
1 have read the h ccutous materials rcqulmments under Chapof 6.95 of me Califon
nia HcaW&Safety Cale,Secuuaz 25505.25531 and 25534.1 undersand motif the Willing
docs not cm endy have a Iona.,Waut my responohility w notify the occupant of me
regairementsw n rlswa-rot
or
auaneenncen;fieatenreep r Signature ofApplicant
Date
C a G�
ow m.mm�nxed ,Co,
D,m All roof coverings to be Class"B" or better