04030036 CITY OF CUPEWrINO "_ 7AW57 0`
BUILDING DIVISION PERMITCOlyTRACTORaINFORMATION
BUILDING ADDRESS: PERMIT NO.
04030036
OWNER'S NAME: PERMrT ISSUE DATE
E:JUDY & TIM qH71T
SANITARY 0. �3112 OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
n0, LICENSED CONTRACTOR'S DECLARATION Job Description
C I touchy affirm that I am licensed under provisions of Chapter 9(commencing P
b withllfame d.fief Division7of NCBusineu arW Profruiuv Code.and myliceueu
"or'n imm�mmeaneerrm'' ADD 706 SQ. FT. (ENLARGE KITCHEN/BEDRMS/BATH)
7 j2z License Class Lk.N
n yo Dole Cunuacmr
''' ARCHITECTS DECLARATION
'i e< I understand my plans shall W uxed u public records
,yx
C y Licensed Professional
OWNER-BUILDER DECLARATION
n0 1 hereby.(firm un I am exempt from tW Coons Co License Law for the
p O which meson.(Section 70313.Business and Profusions Coen:Any city m county
a'�$ which da c u n permit m mottoes alter,improve.deermut,or repair ed eaten m
prior to its issuance,alfa requires the applicam far such Mm file a signed stammcm
thathelicensed pursuanttoh)provisions 3the Contractor'ssinesand
PronLawati( Choptcr9 Sq. Ft. Floor Area On
QFC (commencing with Section 7")of Division loftW Business and Profcssio.Codc)ur
A,
$ dust he Is exempt dterefrom and the Iuu for the alleged cumption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicam in a civil penalty of 3 6VIIUt 3e10 0 ccupancy Type
not mom Nan five hundred dollars(5500). p
I,as owner of the property,ear my employees with wag.u Heir role eom...tiea, u
will do she work,and the stoctum is not intended or offered for sale(Sec.7044,Business
And Professions Code:The C.Acomme,License law dose oat apply an an owner of Required Inspections
property,who Wilds orimprovuthermn.and whodocasuchwmk himselfor through his
own employees,provided Nal such improvements art not intended ear oRared for sale.If,
however,the building or improvement is sold within one year of completion.the owner
builder will have the Wrden of proving that W did not Wild ear improve for purpose of
t 7.
owner of the property,Ho.elusively convecting with licensed cammotma to
cimQt the project(Sec 7044.Business and Professions Code:)The Contractors Li-
cense Law docs not apply m an owner of proPeny who Wilds or improv.thereon.and
who commeas for such projects with a eoonemr(s)licensed pursuant in the Contnnofs
License Law.
I e..p�,.3n�der�Stt. B k P C for this reason
r .Y�Vk�tNl Date 7-
OR COMPENSATION DECLARATION
I heaby affirm under penalty. perjury ore of the fpllpwin Iantions:
have and will maintain a Cenifcare of Caused to self Asum for WorkersCompcn-
prion,m provided for by Section 37M of the Labor Coes,for the performance of dan
work for which this parmit is issued.
1 have and will maintain Worker's Compensation Insurance,m requimd by Section
17W of On,labor Cade.for the Performance of the work for which thus Permit is issued.
My Worker's Compensation Insurance carper and Policy number am:
Carnet'. Policy No.:
CERTIFICATE OF EXEM PnON FROM WORKERS'
COMPENSATION INSURANCE
mus section need not W completed if tW permit is form.hundred dollars(SIM)
nr lesa)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so az to become subject o be Workeri CamPensation
Laws of California Date
Applicant
NOTICE TO APPLICANT:IL aper making this Cenifmate of Eaemption,you should
Income subject to the Worker's ComPeatation provisions of the Ice Wr Code,you muss
.JO forthwith comply with such mvisions or this Permit shall W deemed revoked.
z h CONSTRUCTION LENDING AGENCY
[r (hereby Air.Nat there is a construction lending agency for the performance of
Zea 7 the work for which this permit is issued(Sen.3M,Civ.C.)
W Q Lender's Name
,=z Lender's Address
J C) I certify Nu I have mad this application and sus¢that use above information is
Ly Fcmmct.1 agree to comply with all city and county oNinances and state laws misting to ------— -
LJ building conswction,antl hereby authorin rtpresenutivsts of Nis city wcnter opnn Ne
r W above-numurecd property for inspecd
tion purpose
(We)acme I.save,indemnify and keep harmless doe City of Cupertino against
liabiliues,judgmcnq cos¢and expenses which may in any way ancon against said City
V z APPLICANTeUNDERSTANDS AND ing f this TWILL COMPLY WITH ALL NON-POINT Issued by: at
SOURCE REGULATIONS. ?J O t/--o+
Re-roofs
$ignmWhe 'of Apc UComacmr W
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tW applicant or future Wilding occupant more or handle harardous ma¢nal
As de0nc0 by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
code,section 25572(a)7 �/ All roofs shall be ins inspected prior to an roofing aerial beim
❑Yes NINA P P Y g g installed.
Will do,applicant or future Wilding occupant can equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air conmMnanrs As defined by the Bay Area Air Quality Management all new materials for inspection.
lie W17 /
p Yes �f o
1 have mad the hmardousmaterials requirements under Chapmrfi 95 of the Califor-
.is Hoddt k SafctyCodc.Soon.255115.35533 and 25514.1 understand Natifum building -
does print y bme a tenant that it 4 my reawarshility w noufy the occupam of the
mqui enmwhichmambemetpnonaissuanaofeCcrtif of 'apancy. Signature of Applicant Date
per or..thane enl Dat All roof coverings to be Class"B"or better