04100165 (2) CITY OF CUPERTINO "{ + ''-°?ice ...." ..
BUILDING DIVISION PERMIT xfi -O. RACTOR` NEORMATIQN
BUILDING ADDRESS: PERMIT NO.
POSSIBILITY KITCHENS 04100165
_1�oill 1 11111-9 BR
OWNER' AM PERMRISSUE DATE
IE:
SANITARY OL N0.
(408) 924 0204
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION
ZC 1 thereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
<U with Section]IXI(1)of Division 3of Ne Businusand Professions Code.and my license is
in full forte and effect.
$Ej= LimnseClass LIc.N KITCHEN REMODEL
Z;:, Dam Comncmr
ARCHITECTS DECLARATION
4i�i 1 undcnund my plans shall W used u public records
7yU
C Licensed Professional
3 Oat I am exempt
from
m Ce Concr ON
<0 I hcrehy alarm that 11. .Burin from tW Conmracmr'a is A License Law for the
xO o following.I.A (Sation 9(131.5,Business and Pe,dt.os Cade:Any cin os rnumy
m which requirm a permit min.ffi t,alcor,improve,demand Or a sig any uncturt
rZ i prim In its also mqe the movisio s of far.uth Contra rtni0o(cLicense Law smnmcm
<
that Wi&cirig won section
come pmwaiem of of Contractor's m!Prorlsmis Centel M, Sq.F[.Floor Area Valu t'
,f$ (cat he is xempt wontheeion and di Divisionr of theeged essandon.Anyovi Code)un
Net he is 31.5 b any
and me per for bj alleged exemption.to Any violation of
Semon thantbyairyapplicantforapamltsubjectsmeapplicantmacivilpenaltyof er Occupancy Type
not mom men two hundred dollars(5500). 3�Cl'U fYl7Yf. (](] -
❑I,As owner of the property,or my cmploycu with wages as their sale compensmon,
will do the work and me awcmre is not intended oralfered forsale(See.]oda,Businma
and Professions Code:The Convector's License Law dors not apply m in owner of Required Inspections -
property who Wilds mimproves meson,and whodmcaamhwark himself ormnW h his
Own employees.provided that such improvements eta not intended or offend for We.If.
Wilderhowevr,the avec ebrdeno proving
within Wild
of completion,the e t�� (, ��p
Wilder r.th have the burden imp of proving that be did not Wild or improve for purpose Owner.of
IBpI� V®`B@�Iit {n�Im
salt.).
EU
❑1.as owner of the pmpeny,am exclusively contracting with licensed contractors m
contriver do project(Sm.7W.Business and Professions Cade)The Contractor's Li. APR '2- �OO V .
come lam w does not apply an owner of property who Wilds or improves thereon.area
who contracts for such projects with a contractor(&)licensed pursuant o me Contractor's
License Law.
C3I am uampt coder .B&PDate /COTorr�thi3 reeuaN IIt�}Ja(/t`yl' )II/VI II��I4pI'(p/�`—y}��
O rqr MPENSATION DECLARATION r f I v �/ L®111 �1 `G;1'
/ I be aRirtn under pcnilty of perjury one of the following bo_
1 have and will maintain aCenificate of Consent to self--insure for WmIcesCompcn-
W on,As provided for by Section 3700 of the labor Coda Im me perfonnamx of the
work for which this psnnit is issued.
1 have and will maintain Worker's Compensation Insurance,As respired by Section
37M of me Labor Code,for me performance of me work for which this permit is issued. -
My Worker's Compensation Insurance casia and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thuucrion need not W completed if the permit is formic hundred dollars tg1IR)
or less.) ,
I eenify that in the performance of the work for which this Permit is issued.I.bill not
employ any person in any member so as to become subjmnn tW Worked'Cmmpemation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenifica a of Exemption.you should
become subject to the Woher's Compensation previsions of me Letter Code,you mol
.�Z forthwith comply with such provisions or this permit shall W decreed revoked.
ZO CONSTRUCTION LENDING AGENCY
I-+N Ihereby affirm that men is a cmnsuoction lending agency for the perfmenarim of
Ci 7 me work for which this permit is issued(Sec.3097,Civ.C.)
Le dcr' Namc
a z Uedte:Address
U O 1 eenify that 1 have read this application and state that the above information is
correct.I at=to comply with all city and county ordinances and state laws relating to
DU abbuildingn
above-mentioned
iogmd fenny authonprepmescnmtiwz of thisciryto enmrupnn me
(We)agree 1..cove,indemnify end kith hay in m ma City ro Cupcnino Against
N
liabilities,jrecofthelpsnAnd expcnsm which mryin any way attme agaimueid City
U z A coLICuenceUND granting ofth D WILL COMPLY WITH ALL NON-POINT Issued by: Date
S R R
a 6 10 k Re-roofs
Signs w ficamiCtmoscror f Oak,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will on,applicant or furore Wilding oceupmumm or handle hazardous mann d
u defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safay
cmW,Section or zss3z(aj9m All roofs shall be inspected prior to any roofing material being installed.
mWill the applicant or more Wilding Occupant use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it ha+.Nous air crucermanu u dcfired by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Ym +u
I have maJ ha ardous :a lsmquiremenuunarChaper6.95ofine Califon
iia He.hh&S C .Sccy9. f11. 5533and]53a.lundcnmumsiftW Wilding
data nm cu d h j it is my respon"molity m nndly the Occupant the
rNmocme l e muenceofaCertificateofDecupana Signature ofApplicant Date
b
owner Date All roof coverings to be Class "B"or better