05060127 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,
BUILDING ADDRESS: EGGV CONSTRUCTION INC PERMIT No 05060127
1
itERS NAME: PERMIT ISSUE DATE
THANDIA POMAR ES
NF,: - SANITARY NO. CONTROL NO.
(408) 898-0113
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACOWS DECLARATION
ro 1 Wrtby affirm Nat I On liecased under provisions of Chapter 9(commencing Job Description
4u with Sermon 7"pofDivision 3 of Me Business and Profession,code,and my license is
n« infullfnmeendcffcct 2 7 KITCHEN REMODEL/UPGRA'DE, h2LR'• SERVICE
j�= Lo"m CJlnss_ _ � Lic.g t
nt-� Dam ([$ Contracmr «r tr t)I _ 11 �t=s I
ARCHITECTS DECLARATION
E U I understand my plans shell W used as public mentis (�
T a t, Licensed Prefoomm.l 7 l-e3`ar
OWNER-BUILDER DECLARATION
qy 1 Wmby affirm Nal 1 am exempt from tae Contractor'S License Law for the
•
00 following mason.($..users 703 1.5,Business and Professions Code:Any city oa county rw'. n -'--va
X. which requires a permit m constmcL alee improve,demolish,or repair any mmeture 23760
Lai prior to its issuance.also mquims the applicant for much permit to file asigned statement
< dust WLslicensed pursu.ortoMeprovisions.(Me Contractor's Lid.Law(CIOIMI9 Sq.Ft. Floor Area. Valuation
(commencing with Section 7")of Division 3 ordm Business and Professions CON)or
i 3$ dot hes exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 1031.5 by any applicant far a permit subjects Ne applicant to a civil penalty or 3"N1`1la3bP1 Q 0 Occupancy Type
not more Nan five hundred dollars(SSW).
❑1,as owner of the Property,as my,mploycer with wager u their sol,compensation,
will d0 die work,and the sWCWR is not amended or Offered formic(Sec.70U,Business
and Profeisions Code:The Contractor's Licenx law Most wt apply in an owner of Required Inspections
propeny who builds or improves thereon.and who does such work himself or through his
awn employees.provided that such improsemcnts art not intended or offered forsals.If.
however.Ne building or improvement is sold within one year of completion,Ne owner.
builder will have thc burden of proving that he did not Wild or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
consumer thc project(Sec.7O .Business and Professions Code:)13m Conuzewr's Li
cense taw does not apply to an owner o(property,who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant o Ne Contractor's
License Law.
❑I am exempt under See ,B&PC for this moon
Dee
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of 0m following d,clantiona
I have and will maintain a Cer ificate of Consent to self-insure for Worker's Compcm
smion,as provided for by Section 3700 of the Labor Cade,for Ne pcsfmrmomc,of the
work for which this permit is issued.
Xhave and will maintain WaTlums Compensation buunna,as required by Smmon
of Ne Labor Code,for the perfermmee of Ma work for which this permit is issued.
My Worker's Compensation Insurance carrier end Policy numher 2:
Came,. STATE F01D Policy No.:I7 082 vl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W complced if the permit is foram.hundred dollars(SIM)
or Icsa.)
I certify Net in the performance m(Ne work for which this permit u issued.1 shell nm
employ any Noted in any mann sin yl become}ubimtto the Workers'Compcnsadon
Laws ofCali ror't�aAApplicaut 14 %�
NOTICE TO APPLICANT:If,after making this Ccnif c of Exemption.you should
become Subject m the Wohv's Compensation prove s of the Labor Cock,you mum
.JO forthwith comply wild such provisions or this permit shall W trimmed revoked,
'z N CONSTRUCTION LENDING AGENCY
(-r•� I hereby afrm that dere is.cm.,inn hndingag,ocy for de pcif...or '
Ne work for which this permit is issued(Sec.3091,Co.C.)
4] Lender's Name
z Lenderi Address
J Q I cenify that I have read this application will some that the above inforreaoun Is
ly cora I agree in comply with all city and county ordire mers and some laws relating to
D V building construction.and hereby atrthorrre mpmsentatives of this city in enter upon Ne
r� above-mentioned property for inspection purposes.
(Wju agree to eve,and expert and tech harmless the City of =gamin id City
F"CL liabilitler.judgmcnu.costs and expenses which may in any way accmc against aid City
Z in
of Me gorming of
his iscook.
U — APPLICANT eUNDERSTANDS tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date U O ^
SOURCE REGULATIONS.
Re-roofs
Signature pf AsaPlicaDae
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or forum building e,Chapter
store or handle ha,arduus material
az defined io the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
.Section 25532(a)?AF
/ ❑Yes pA Nu All roofs shall be inspected prior to any roofing material being installed.Will the applicant or future building occupant If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnns air contaminants as defined by the Bayy A Arta equipment or devices which Air Quality Management all new materials for inspection.
District?
❑Yes 'C/�N.
HIV
mad Ne haurdmss maerials mquimmcnu under Chaper 6.959!thc Califor-
eiaHcelth&SsfetyCode.Seetiars25505.25533 ar,JZ534.l understand mm ifthe Wilding
does rot cuncntiy have a ena.L that it is my rcaponot ilh,0 priory ore..Pal of de
require pts - mumW da m' uamm.o(a ficaeofOccupancy
. Signature ofApplicant Date
Owner Or auth circd egcnt Dae All roof coverings to be Class"B"or better