04010139 CITY OF CUPS WFINO >�.. :'2'G .'a �?i '?b�vs•.��xF BUILDING DIVISION DIVISION PERMIT CONTRACTOR INFORMATION ,
BUILDING ADDRESS: PERMIT Nb4010139 4010139
'ER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY NO. CONTROL NO.
ARCHITECVENGINEER: BUILDING PERMIT INFO
E B MECH
°00 LICENSED CONTRACTOR'S DECLARATION- O
u❑ h SI hcrcby affirm that 1 am licensed trader pmviaiaas of Chaplor 9(commencing Job Descripti
�W with 7")of Division J offs:Business and Prefcssiono Code,and my license is
I.mnClass Li,.amm erre"
D Licnnn REMODEL KITCHEN & 3 BATHRMS NOV 144'1-' 2004
i x
4—n Dale Contractor
'£R',J' ARCHITECTS DECLARATION
?K 1 undervand my plain shall M1c used as public mcards
is
Licensed Pmfessinnal
rn 5 OWNER BUILDER DECLARATION V
<y 1 hereby affirm that I am exempt from the Contractor's License Lew for lire
00 following mason.(Section 7031.5.Business and Professions Cods:Any city or county
K$ which mquira a permit to eonstroca alter,improv,demolish,or repair any structure
tri j, prior in its iudancc,also requires lhcapplicant for such permiud rile a signed statement
£pSS<
that he is licenscil pursuant bi the provisions(if The Commeam'S License Law(Chapter 9 Sq.Ft, Floor Area Valuation
(commencing with Section 7000)of Division 3 or the Business and Profusions Cook)or
i $ Nat be is exempt therefrom and the basis for the allsgcd exemption.Any violation of r�t».tsxi�n,a-t,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 I9LM9uel0 0 Occupancy Type
not mom than five hundred dollars(sofa. P Y YP
❑1,as owner of the pre,ery,or my employees with wagca u their sole compensation,
will do the work,and the strucmm is not intended or offered for sale(Sec.70,14,Business
and Professions Code:The Conuslari License law dux not apply to an owner of Required Inspections
property who builds or fmproates thereon,and who does such work himself or through his
own smployi ee,provided that such improvements are not intended or offered for sale.If.
however,Use building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not Wild or improve for PmpOW of
sale.).
1,as Owner of the property,am exclusively contracting with licensed contractors to
omtruct line project(Sec.70M.Business and Profesniarts Cocky The Contrntors Li. .
cense law does not apply to in owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractors)Bosomed pursuant to the Contractors
License law.
I am exempt finer Se .B h PC for this(nars"IN
Dae
OR OMPENSATION DECLARATION
1 hcmby in.under penalty of perjury ons of the following declarations;
I have and will maintain a Ccrafcnlo of Consent to self-imum for Workers Comrcn-
aarion,ss provided for by Section 37M or Ne labor Code,for Ne performance of the
weak for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for to performance of the work for which this permit is issued.
My Worker's Compensation Insumnce carrier and Policy number art:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisaeelirm...door W campined Urine permil is fir one ndmdmd dollars($100)
or tests.)
1 unify that in the perfommatcc of the work for which this permit is isaucd,1 shall nut
employ any rc Inn in any manner M as in become abject to the Workers'Compensation
Laws of Califomia.Dat
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker Compmxalion provisions of the labor Code,you must
�Z foMwilb comply with such ponviia.or this permitahall he becro d revoked. .. .
z CONSTRUCTION LENDING AGENCY
P4 I hereby affirm that there is a construction lending agency ror the performance of -
CL > the work for which this permit is issued(Sec.3V)7,Civ.C.)
U] Lender's Name
0. Lender's Address
D Z
U O I certify Nn 1 have read this application and state that the above information is
It, F' coacet.1 agree to comply with all city and county ordinances and slam laws relating to
0 building construction,and hereby aulhorin represenutives of this city in color drum the
r W above-mentioned pmpeny roe inspection purposes
FG (We)agree to saw.indemnify and keep harmless(be City of Cupcnmo against
' rq liabilities.judgments.costs and expenses which may in any way accmc against MidCity
U Z in conacgdcnoe of the graining of this permit.
APPLICANT UNDEPTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
SOURC LA NS. �/ '
/ 2y "N Re-roofs
aware OLA li OMC mr arc
ABDOUS MATERIALS DISCLOSUR Type of Roof
r Will the applicant or furore building Occupant store or handle hacardevs marenal
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
e. rlYea zss3zca7 All roofs shall be inspected prior to an roofing material beim
❑Yea No P P Y g g installed.
( If a roof is installed without first obtaining an inspection,I agree to remove
Will furs air Contaminants
or furore building occupant A equipment or tlMana which g
emit hov.ardnus air conmminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ($f Nd
1 hav real the haaaNrmsmaterialsmquimmcntsunderCNpmr6.95of0 Califon
trio Health KSafnyCode.Sceau SNI5,135J3 and85bs.1 undersand thalifthe Wilding
does not euncndy a¢nes .that it is my responsibility m notify the Use, fit of
regimmcnts which 'usspoor mlMuamem of a Cenificateof Occupnc. a Signature of Applicant Date
owner dradmoriye agent All roof coverings to be Class "B" or better