03090109 CITY OF CUPEWHNO "M +zy si
BUILDING DIVISION PERMIT �,, QNTRAC I2 I,NW"' A'TION
BU I LDING ADDRESS: PERMIT N003090109
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:R'S NAME: PERMIT ISSUE DATE
HANOCH & BATSHEVA RAVIV 11/13/2003
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC14
ioo LICENSED CONTRACTOR'S DECLARATION
£to P I hereby effort That 1 am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 71)(M))of Division 3 ofthe Businesxand Profession.,Cndarnd my licemend
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in full forte and.Meet. ADD 678 . 86 SQ. FT. /KITCHEN REMODEL
7�? License Clan Contractor
ARCHITECTS
.
O Dae Can DECLARATION AsidallErTSDsmbli, cmd, ADD COPY FEES $6 . 40 (32 PS) 10/24/03
I u U I undcrsund my plans shall be vud u public mrnrds
e a' innal
O Licensed
g OWNER-BUILDER DE
I CLARATION
<E hencscrchy affirm on I am cBmmpl from the Contractor's Liccnu Law for the
0 o following reason.(Section 7,vica Business and improve.
dr inns Core:Any city or county
<m which require..,a permit m construe,aper,int for Such
h Permit t file
repair any structurgned statement
VEy that hor niuiensedprsu myo thenes theapplicantfor Cormanrmd roicense aw(Chmmcm
fir$< Iharhmslicened pursuant lndm of Divisio nr the he Businessnd Proclzw(Chap¢r9 Sq. Ft. Floor Area alas '
recommencing with Section 70(IU)n(DivixipnJnf the Business and PmfcssiansCMc)or
That he is exempt thcmfrum and the basis far Ne alleged exemption.Any violation of $12
Section 7011.5 by any applicant for a permit the applicant to a civil penalty of APN Number u nc T
oat mare than five hundred dmlarx($500). - Y YP
❑ LssowncroRhe progeny,ormycmployee who wagrxasthdr solcmampensatinn, 36924003 . 00
will du Ne work,and the xtrunurc is not intended or ofemd for sale(Sec.70u,Business
and Professions Code:The Contractor's License Law does not apply to an owner or Required Inspections
property who builds m improves thereon,and who deas such work himeclf or through his
wn employees,provided thatsuch improvements are nut intended oroRered for sale.It,
however,the building or improvement is sold within one year of mmplction.the owner
builder will have the burden of proving that he did not Wild or improve for mrpox of
sale.).
O 1,as owner of the Pfopefty,am exclusively contracting with licensed contractors to
constrict the project(Sea.7W.Business and Professions Code:)The Co crowtoi s Li.
menu law docs not apply to an owner of property who Wilds at improves themon.and.
who contracts fur such projects with a contractor(s)licensed pursuant to the Contractor s
Liccnu Law.
1 am exempt our Sec B&P C for this reason
i m 7v- � n
WORKER'S CQMp2 ATION BIiC A ION
jif
1 hereby aBirm under penalty of perjury one or the following declarations:
0 I have and will maintain a Cenificam of Consent o self-insum for Worker's Compere
ration,as provided for by Section 3700 of the labor Code.for the performance of the
work ror which this permit is issued.
C I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of thc labor Code,for the performance of Ne work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number aa:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($191)
or Ica.)
1 certify that in the perromunce of the work for which his permit u issued,I shall nal
employ any person in any manner so as to becum,subject the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificate of Exemption,you should _
become subject to the Worker's Compensation provisions or the Labor Code,you must
O forthwl lh comply with such provisions or this Permit shall W deemed revoked.
Z eyed.. CONSTRURION LENDING AGENCY
I hereby affirm that there is a construction lending agency lot the performance of
the work for which this permit is issued(Sec.3197,Civ.C.)
:gd Lender's Name
z Lender's Address
U O 1 codify that 1 have fead this application sad sure that Ne above information is
Fcorrect.1 agree to comply with all city and county ordinances and sure laws relating Io
•JU building construction,and hereby authorize representatives of his city to enter upon Ne
4 above mentioned progeny for insp¢don purposes.
(We)agree h save,indemnify this and keep harmless the City of Cupcdino against
F'[n
Liabilities,programme.costs and expenses which may in any way accrue against said City
U z A PLIC N71' of the granting of This Permit. d
y APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGU�,IONS.
��nb+•I� k Re-roofs
signature of Applrtanucantracmr Date
. HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will one applicant or future building Occupant store or handle baiardous material
Idcfncd by die Cupeni no Municipal Codc.Chapter 9.12.and the Health and Safety
m, 0yea zsslz(an All roofs shall be inspected prior to"an roofing material being❑Yes TNu P P Y g g installed.
Will thea applicant or r7atLan building occu ant use a If a roof is installed without first obtaining an inspection,I agree to remove
PP g P equipment or devices which
emit hazardaux air contaminants as defined by the Bay Arca Air Quality Management
DixlricR all new materials for inspection.
❑Yes $j NO
I have read the harardnus materials requirements under .Chapter 6.95 of the Califor.
nix Health&Safety Co ,S u..25505.35531and25534.1 umkrsund thadid Bic Wilding
docs not currently haw a oxonaL Nm it is my rexpomihili y m nobly the weup rat M the
requirements which mus mel prior it)issuance of a CCMFICac of Occupancy. Signature of Applicant Date
dN- '" All roof coverings to be Class 'B" or better
wnerotb
r auodvcd gent Da g