04060191 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ONTRACTOR INFORMATION: ',
BUILDING ADDRESS: PERMIT'904060191
OQ4060191
10284 CPEqTON DR
OWNER'S NAME: PERMITLSSUEDA'IE
'4ARTIN & LAURALEE SORE EN
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
uoo
LICENSED CONTRACTOR'SDECLARATION Job Description
cap:F1 Moiety affirm that I am licensed under provisions of Chapter 9(commencing
<u with Section 7")of Division 3 ofthe Business and Professium Code.and my boom is
"cm inlvnfnmeaneerreet. ADD 81 SQ. FT. FOR KITCHEN/RENODEL
5�Z Licenu Clan Lie.#
Z F C on, Carriacou -
; ARCHITECTS DECLARATION
I understand my plans shall he used as public records -
�dv
Licensed Pmfcssional
S OWNER-BUILDER DECLARATION
ray I naso .IRam that I sum exempt from the Cortins Co License Law for IW
i p O w lowing lino..(Senlun]1131.5,Business and sae.deamfi Code:Any city or county
m iYa which inquires a permit w eonswct,alcor.impmw,demnliah,or repair any suuewn
,�oi prior to its issuance,also requires the applicant for such permit o file a signed slaMrW Tit
< that he is licensed pulauent to the provisions of the Contractor's License law Chapter Sq.F[. Floor Area Valuation
wiS (commencing with Section]OW)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applinrd for a permit subjects the applicant to a civil penalty of u3hibefi 0 Occupancy Type
nm mon than five hundred dollars(5500).
I,as owner of the property.Or my employees with wages u Neh sale compensation.
will do the work.and Nc swan¢is not intended of offered for sale(Sec.7044,Business t
and Professions Code:The Conuactore Licenu Law does not apply to an owner of Required Inspections -
property who Wilds or improws theman,and who does awh work himself or though his
Own employees,provided Nat sm
k Wuch improveentsre anot intended oroffered hostile.IL
however,the building or improvement is sold within one year of compledon,Ne owner,
builder will now Iaders of proving Nat he did not build or improv for purpose of
salede ••'CJ Y
C)1,as owner of the propeny,am exclusively contracting with licensed contractors;in
conswct me project(Sec.71144.Business and PmGssions Code:)The Con Tawas Li. v1�
nae law docs not apply to an owner of progeny who Wilds or improves thereon,and.
who contracts for such pmjects with a contractors)licensed pursuant to the Compactors V
License Law.
ri I inn ex pt underr]Sec. -s B&P C for this reason
riee..�/'6//l A'Lly W Date e,
WORKER'S COMPENSATION DECLARATION
1 hereby afflon under penalty of perjury one of the Winning��ll\col ations:
haw and will maintain a Certificate of Consento seure forN'Rrkelf-instsCconNo-
moon,as provided for by Section 3700 of Ne labor Code,for the performance of the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensmion Insurance,as"tried by Section
37M of the labor Code,for the pcdormance of one work for which this permit is issued.
My Workers CnmPeaam.Iaoancc came,and Policy number am:
Cartier: Policy No.: '
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
mussection mcdnotWcompletedifthepetmitisforonc Wnd 4ollars(SIBB) '
in leu.)
1 cenify Nat in the performance of Ne work for which this permit is issued.I shall not ,
employ any person in any manner an a to become subject to the Worlmot Compensation
Law.of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificem or Exemption,you should
become subject to the Workers Compensation provisions of the UNO Code,YOU must
.JO forthwith comply with such provisions or Nu permit snarl W rimmed!evoked.
Z2 CONSTRUCTION LENDING AGENCY
F•'4 I hereby aM.that Inert iso convection lending agency for the pe,fi mlance of
C> the work for which this permit is issued(Sec.3097.Civ.C.)
yQ Urider's Namc
= z Lender's Address
C)Q 1 cenify that I have mad this city
and county
and sum Nat the,salve information miming is
^F cordo 1.gale m comply with all city and county nNinanas and sou laws r upon
c
OU anon-gconones! ogand for nycedon prepresentatives of Niscity ocmcr upon Nc
r shove mentioned to property for impecd an purposes
(Wc)agree eto an.indemnifyandkeep may
wyacruCupenstsidno City
Uy costs expenses which may in any way accrue against said City
V z AeonuquNT of Ntgaming of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINf Issued by: Date
SO EREGULATIONS.
"1 Re-roofs
Ig cele ofAppnt HAZARDOUS MATERIALS DISCLOSU� Dam Type of Roof
Will the applicant or future building Occupant son or handle hazardous material
Us defined by the Caperton Municipal Cods,Chapter 9.13,and the Health and Safety
cdda.seeYenzss3zcan ��- ppp All roofs shall be inspected prior to any roofing material being installed.
Yes Y,YfNo
Will me appfiesm or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes NNo
I have mail the hasrddws materials nquiremenu under Chapter 6.95 of Ne Califon /—
niaHtaldd&Safety Code,secants 8505.25533 and 25534.1 understand Nat if the Wilding q
dao not curtcndy bow a manna Nat it a my respomihilky an mall'y the oce.pam of the l, OC.
requirement an mum W met poor ccofa Ccnificao:of Occupanc,. ore Of App ICaDI z D
`L Z'
ow or momcd.gent Data All roof coverings to be Class' or better