02100111 CITY OF CUPERTINOvie,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUIrpB(5ApDRFALLENLEAF LA PROGRESSIVE GENERAL CONST PERMIrNO2100111
IFIINAMELAINE F AND GENE S 1691 PHANTOM AVE APPucA`Tr0`YB1D5rY2002
PHONE: (408) 371-8007 SANITARY NO. CONTROL NO.
ARC HITECITENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MELD
00Z C� 0
�00 LICENSED CONIRACfOR'S DECLARATION
ad I rotor,swim that l am licensed ander provisions or Chapter mommem ing KITCHEN REMODEILfb Description
tai wih Section7410)of Division Sof he Buvnese and Not 1ai1 Card aril my license is
in fu 11 brrtca doff c�.j •V�
Z Liccnsa Class k,]'y 'S
17
0 m O Dab _Co.,Quacmr
ARCI,ITECI' C RA
�it< ..X1 .1aComoro my planaruwaced as nc Tec tr /
.e°dG
ilv0.° Licensed Pmlcssiowl
S OWNER exempt BUILDER theCntr10N
Cei w a y 1 hereby affirm that 1 am cacmpl from Inc Contractor
Littre Law for the $16000
w 900 fullnwing reaoa(Section]1131.5.Business and Professions Code:Any city lir county
C,
�x which requires a permit at construct,a1mr,improve,demolish.nr repair any aUuemrd
prior to its issuance,also requires the applicant for such permiuo file a signed statement t£-�< that he is licensed pursuant or the provisions of the ContmclaLS License Law(Chapter 9 3ffy9Hffl(2)9A@@ Valuation
y C (cum mending with Section 8X01)or Division 3 of the Business and Professions Cod0on
i 3 Inst he is cumin therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a pormad ioncedo he applicant to a civil penalty of Occupancy Type
not more than rive hundred dollars(S5110). 102P - PIERS P Y yP
❑1,a owner Of the property,lir my employers with wages as their sole compensation,
will do the work,and the statement is not intended or offered for sale(Sec.]Ola,Bec
and Pmfeesbns code:The Contactors License Law dins not apply to an owner or 104 — REBAR Required Inspections
property who builds or improves Bomar.and who does such work himsclfor through his
Own employees.prodded that such improsmmene and not intended Motioned for sale.If, 10S — ANCHOR BOLTS
however.the wilding or improvement is sold within one year of completion,theowner- lO6 — SEWER & WATER
builder will the e burden of proving mal he did not build or improve for purpose or
sola')' 202 — UNDERFLOOR PLUMBING
❑I,as owner of the propertyam exclusively contracting with licensed Contractors to 203 - UNDERFLOOR MECHANICAL
Construct the project(Sec.]OW,Business and Professions Code:)The Contractor's Li-
censelawdoesnotapplytoanownerorProperty who wads or improves daemon.and 204 — UNDERFLOOR FRAME
who russet for such pmjecswida inuactons)licensed pursuantto dae Contractor's
Lice Law. 205 - UNDERFLOOR INSULATION
am
am exempt under Sec. B m P c for his rcaoa 301 - ROUGH PLUMBING
cr std 302 - TUB & OR SHOWER
WORKER'S COMPENSATIONDE R ION 303 - ROUGH MECHANICAL
1 1 herebya1Btm under It f e of he ollowin declarations:
Penalty g 304 - ROUGH ELECTRICAL
❑I nave and will maintain eCertificate of Cunene In Calf-insure for Worker's ed M and
sntinn,ae pnrviJed for by Section 3]1X)of the labor Code,ha he performanm of Ire 3 05 - FRAME
work for which dais permit is issued. 306 - HOLDOWNS
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section 307 - INSULATION
3]110 of db Labor Crate,for the performance of the work for which his permit is is and,
My Workers ComprmsadonInsurancecarrierandPolicymanheram: 308 - SHEETROCK
ca"°° Policy No: 309 - EXTERIOR LATH
CERTIFICATE WORKERS'
COMPENSATION INSURANCE
310 — INTERIOR LATH
O-Iia,ecaon need not w completed ifnd rcmtit is for one hundred dollars(Huk) 311 - SCRATCH COAT
Of let's') 313 - ROOF NAIL
I canny mat in he Cerro der of me work Tor wmdh dais Correa is ssaca. shml not 501
- FINAL ELECTRICAL ENERGY
cmpiny anyppeeanti n m rr$�G�m the Workers Compensation
Anncal$on Da ' nr` o�,i 502 - FINAL PLUMBING ENERGY
Rar
11J/SC�I:roA 1 11�ivr: arrmakingmiscon isionsoftheLaborode.younmum 503 - FINAL MECHANICAL ENERGY
R'enwesubjcnm flit such
Comp or this
of rehaborke you must 504 - FINAL BUILDING ENERGY
O ,Z forthwith comply with such provisions or his lkrmil shall adeemed rcvokcd.
Z o CONST RUCr10NLENDING AGENCY 505 - FINAL ELECTRICAL
F = l hereby affirm COOITCis a Constrictor lending agency to perBnmance'd 506 — GAS TEST
a >
f116the work]no which th'Permit isissaed(See.30U,CryC.) 507 - FINAL PLUMBING
Lender's Name
] 2 Leader's Address 508 - FINAL MECHANICAL
UO Icddifyn0ythat 1haw mad this
ty and counandsetahat Iwsavews relating is 509 - FINAL GRADE
Ly F corzen.1 agree m comply with all any and county ordinances and state laws relating nr
U wilding Construction,and hereby authnrnc representatives of his City to enter loved he 5 FINAL PLANNING
above confined pm,,ty for inspection Fypurposes.(We)agreemsave,indemnifyandkapharmlesstheCityofCuporinoagainst 14 - FIN BLIC W RKS
y liabilities,judgments,Cosa and expenses which may in any way accts against said City
U Z in consequence of the granting of his permit, v v
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by. Date f
SOUR 'RE ULA ONS.
/a a Re-roofs
S" rc t n o n Dab
HAZARDOUS MATERIALS DISCLOSURE. Type of Roof
Will thea Iicanl Or fame building¢cupam smrc orhandle historians material
r JCEned by he Cupen;no Municipal Crde.Chapter 9.12,and he Health and Safely
C.Section 25532(a)'! -
Owl 01N. All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant(it ream wilding rxcapam use equipment or dances which P
trait hvallous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dlsvictl Wo
t]Ycs
1 have mall he wraMeas reabriaB requirements an&,Chapter 6.95 ufhe Calibur
ria I teeth dt Safely Cidc,Scomn,25505,2.5533 and 25531.I undeeswnd h:n if Be milJinp
Jrcs nnl rzdnl y havC a knanl.Nat it is my reaprr5ihilily la nndl he taxupanl of @d
req iremr shunter mus lc mel Pacttoconcededofacenir obor��paS}cy Signature of Applicant Date
6'/y'C
Ownetora h rind Font Date All roof coverings to be Class "B" or better