04100049 CITY OF CUPERTINO
Bu1Lollvc olVlsloN PERMIT ,CQNTR°AC�T,ORI,NFORMAT..ION ,,
BUILDING ADDRESS: PERMIT NOh 4 1 0 0 0 4 9
0121 FMPTPR All
OWNER'S NAME: PERMIT ISSUE DATE
JERRY WANQ 9,121
NE: SANITARY NO. CONTROL NO.
ARC HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOp LICENSED CONTRACTOR'S DECLARATION O O O O
I hemby affimr drI I Am BRnsed ander provsions of chapter 9(commencing lob Description
with Section 7")of Division Sof the But.anal Profossioru Code,and my license is
_Oy
in full Claercee`
Z ADD 88 SQ. FT. /KITCHEN REMODEL
p License elates tic.It
FC Dam Contractor
f'Js ARCHITECTS DECLARATION
�z< I understand my plans shall he used as public mcoms
CTU
;0, Licensed Prefessionel
S OWNER-BUILDER DECLARATION
aI herehy amrm that 1 Am exempt fru.Ne Contracmr's License Law for,he
p 0 following reason.(Section 7031.5,Business and Profout urs Code:Any cityof county
$ which reyuims A Permit to eonstmeL AImr.impmve.demolish.Or.pair any structure
prior m its issuance,also require the applicant for such Permit o f Ise a signed stamment
the,he is liccnsod pursuant to the Provisions of the Conlnctori L crus Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business and Professions Corso)or
Wthat he is excmp,thcmffom and,he bazu for the Alleged exemption.Any violation of
Section 7031.5 by any Applicant for A permit subjects lW applicant to a civil penalty of 32d Z41t."gr00 Occupancy Type
not mom than five hundred dollars(5500).
0 I,n ownu of tW pmpwy,dr my wployeo with wage u dcir mle compcnudon,
willdodoworkandIWswctumisnotimmnd morcem forsale(See.70as,Business
and Professions Code:The Contractor.License Law does not apply in An owner of Required Inspections
porIown enywho
yees.provided at such imprve who Are not such in work dedonu endfmugo his FINALE®
awnemployee,provided pr such rat iss sold
wit in not:endedoraQlmd for sok.IL
however.the building or improvement of proving
is halal within one year or completion,the owe of
huildu will have the burden of proving that W did not Wild or improve for purpose of
�m/k�.).
+SIS as owner of the propeny,am exclusively contracting with licensed contractors to sa ••'�/
construct the project(Sec.7W,Business and Professions Cade:)The Contrmmrh U. FoA" /' / 2005
cense law does not apply to an owner of propeny who Wilds or improves themon,and
who contracts for such projects with a comractone licensed pursuant to the Contractor's
Lkenre few. BUILDING 0'a D I� G
0 l Am exempt undo,See. .B&PC for this memo U L I`r'a■
` /n- 'kms D.mto&lot
WORKERSAv
COMPENS TION DECLAR TION
1 hereby Num under penalty of penury enc wing declarations:
lure and will meinuin a Ccnifeam of Consort to self-insure for Worker's C9mpan-
Won,es provided for by Station 3700 of Ilte labor Code,for the performancc of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of roc Labor Code,for the performance of the work for which this pemtil is issued.
My Worker's Compensation Insurantt carrier and Polity number x:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Oris section need no,W completed if 1W permit is for one hundred dollars($101)
or Icss.)
I cenify that in the performance of the work for which this Permit is issued,l shall not
employ any permn in any manner At As to become subjuuothat Wmtrrs'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,Arm,making this Ccnificec of Excmp,ion,you should
become subject to the WoAcr's Compensation previsions of the Is Wr Code.you mord
.JZ forthwith comply with such prnvi6mrs or this permit hall be deemed invoked.
z O CONSTRUCTION LENDING AGENCY
[-. I hereby affirm that there is a construction lending agency for the performance of
Clithe work for which this permit is issued(See.31197.Civ.C.)
GA Unders Name
= Z Lenders Address
U O 1 cenify that 1 have read this application and some that the a W ve inkons ion is
Is. F correct.I agme to comply with all city and county ordinances and arta laws relating 10
pU building construction,and hereby authorim mincremadWs of this city to enter upon the
r C above-mentioned property for inspection purposes.
(We-)agree to save,indemnify and keep harmless the City of Cupertino against
f'i,i liehilitie.judgmcnts,case end expense which may in any way(came agunst mid Ctry
U 2 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OURCE REGULATIONS
_
_n �� Re-roofs
rgnaz ofAppli<HRDOU MATERIALS DISCLOSURE a Type of Roof
Will Ne applicant or(intim Wilding uttupanl atom of Mn0le hvudoa rumen
az defned by tMCO
e CupeA Municipal Cade.Chapter 9.12.and the Heald,and Safety
Code, ccdZ.25532(a)9 All roofs shall be inspected prior to an roofingmaterial being installed.]�aN
Will the applicant or
food building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t bA)ardnu5 Air cmm�mimm u&r,.d by the Bay Area Air Quality Management all new materials for inspection.
ester /tis
❑Yes QFU
I have maJ Ne hvaNnm mamrials myuimmenss under Chap¢,6.95 of IW Glifor
out Health&Safety Cabe,SecWns 25505.25533 And 25334,I undent nd that ifdc Wilding
due not cunen,ly have a to
that it u my msp.sibilily.notify the eauPml of the
ents which mast m ,pdoru,issuanccofa Ccnili.w.fOccup Signature of Applicant Date
Owner. awhOnied age It (O arc All roof coverings to be Class"B"or better