03030086 CITY OF CUPERTINO `` ser->Fw3'a� m s
BUILDING DIVISION PERMIT ICON-gwgTORIINFORiVIA.TION• :.
•+„�.�*&'>t. M sells. :`: ;i�?_. a
PERMITNO.
BUILDING ADDRESS: '
0
PERMIT LSSU
0 .NAME:
:RISA HOLLM -
SANITARY NO L NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECfIENGINEER:
BLDG" ELECT PLUMB MECH
repo LICENSED CONTRACTOR'S DECLARATION Job Description
tic 1 hereby ailuro Nmm
at 1 am licensed under provisions of Chapter 9(scrncing p
U with Section 70M)of Division 3 of the Business and Profession,Code.and my license i, I� �p p TpqT
in fall role,aneerzea KITCHEN REMODEL It—Oa@8lM0'I°F'7at9
'�Z License Class Lie.0
Dam Conuactm
ARCHITECTS DECLARATION ss pyo •1 Q 200'3
1 understand my plain shall be used u public nxnrds H T R t U J
i U
'60 G Licensed Professional q�
OWNER-BUILDER DECLARATION Nra
G
f 1 berthy affirm Nat 1 sm exm the attempt from Commodes License law for the BU'L®I -
s O o following reason.(Section 7031.5,Business end Profcssiom Code:Any city or count
S$ whlcM1 requires.permit n comm the ,tree such
Permit t fi repair arty statement
-Zy
On its issuance,also rcquimnhe applicant for inch Permit file aligned silo:mem
E � Nuheislicensedpurtu.nttcthcPmvisioasortWConmactoraliccvclaw(CMptt9 Sq.Ft. Floor Area Valuation
Y $ (cammctmingwithScdion]OW)nfDivislon3nftheBusinessandRofrsdomCMc)or $25000
.. Nat he is attempt thertlrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fore permit subjects the Applicant m a civil penally of 3°� . `IJ r 0 0 Occupancy Type
not more Nen five hundred dollen($500).
❑1,as owns of the property.or my employees with wages u U¢Ir to compensation,
will do the work.and the structure is not Intended or offered fora-]'(Sec.7044,Business 101 - FOUNDREiITiit Inspections
and Pofessiov Code:The Convenors License Lew does not apply m an owner of
propenywho Wildsorimprows thereon.and who d.,,tach workhimselforthmugh his 102 - PIERS
own cmployces,provided tbasuch lmprewcoons ere notimmnded oroffaM forsale.If. 103 — UFER
however,the building or Improvement Is sold within one year of compledon.the owner-
wildcr .will baro the hurt.of proving that w did not wild or improve for purpose of 104 — REBAR
sale.).
Las Owner of the proper,am exclusively contracting with licensed convectors to 105 - ANCHOR BOLTS
..,met the projen(Sec.704<,Business and Pcolsomme,Code:)]he Cnnvsmors Li- 106 — SEWER & WATER
cense law does not apply to an ownm of properly who Wilda or imprewA themon.rod, 2O2 — UNDERFLOOR PLUMBING
who eontncts for such projects with a eoContractor'sr(s)licensed pursuant the Contractor's
License Law' P C f203 - UNDERFLOOR MECHANICAL
e empl under Sec. B d: m Nb reason '
.LQc_L / 3 t7 0 204 - UNDERFLOOR FRAME
WORKER OMP NSATION DECLASbAbsl 205 - UNDERFLOOR INSULATION
W. ,hereby afntm under Penalty of perjury one orthe following declarations: 301 — ROUGH PLUMBING
I here and will maintain a Certificate ofConvent to self-Insnm for Workers Compen- 302 — TUB & OR SHOWER
section,as prordded for by Section 37x0 of the Vbor Code.ser the pmformence of Be 303 — ROUGH MECHANICAL
wink for which this permit is issued.
1 haw and will maintain Workers Compensation Insurance,as required by Section 304 - ROUGH ELECTRICAL
3700 of the labor Code.for the performance of the work ser which this permit is issued. 305 — FRAME
My Wooers Compeasedon insurance carrier and Policy number am:
Carrie Policy FROM
306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FADM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
Missectmencedractlicco mplewd it the Permit b for One hundred dellas(SIM) 309 7 EXTERIOR LATH
oriel.)
1 ccnify that in the perform. ,e oythe work for which this Permit is issued.l shall not 310 - INTERIOR LATH
employ any person in any a seasmheeme subjectmdmwork.'Compcasnlon 311 — SCRATCH COAT
Lew:of California.Dem
Appne.nt 313 - ROOF NAIL -
NOTICE
TO PLICA! :IL cher maklnF this CcrtiOcete of cmPtian.Ynu should
become nth'0.'.Be
worker Compensation provisions of the labor Code.you must 501 — FINAL ELECTRICAL ENERGY
OO foMwith mMywithauchpmddnn:orthiapermiuhauWeecmedrevnkcd' 502 — FINAL PLUMBING ENERGY
zy CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
jr 1hemhyalfrmdutthertisaconstmctionlendingagencyforthePerformanceof 504 - FINAL BUILDING' ENERGY
7 the work for which this Permit is issued(Sec.3097.Civ.C.) ,
zip Undoes Name 505 - FINAL ELECTRICAL
OW Z Under'sAddress
U O 1 eerily that 1 hew read this application and sum that the shove mromeaw ix 5 0 6 GAS TEST
U, correct-l gree to to comply with 01 cit and count ordinances and scale laws relating to 507 - FINAL PLUMBING
{',�` Wilding cmtsuuetion,and hereby authorise mpmsentaliws or this city to enter upon thc
O" aww-mentioned property for Inspection purposes. 0 FIMtNG AL
(roc)agree to sew,indemnify and keep harmless the City of Cupertino against 0 9 F 1
rn
liabilities judgment.costs and cape.which may in any way accrue against aid City
U Z in eon"uence of the granting of this permit.
^� APPLICANT UNDERSTAND AND WILL COMPLY Wfm�ALL NON-POINT Issued by:5 Date
SOURCERE ATIONS j' V)g
Re-roofs
tgnuurt ofAppliHAZARDOUS MATERIALS DISCLOSURE 'MICLOr Date Type of Roof
Will the applicant or future building occupml stow or handle hvarEom material
-fined by Be Cupenim Municipal Code.Chapter 9.11.and the Health and Safety
Section 255324)? �Hn All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment m device,which If a roof is installed without first obtaining an inspection,I agree to remove
emit ovations air comsminams as dc5med by the Bay Area Air Quality Management all new materials for inspection.
DinricR ,�[
DYcs /A1 No - -
lb.w.WOehvardmnmaterialsrt uimmensunderChapmr6.95oftheCeliror-
nief3celN�SefctyCalc,Sccciam 73N)5.13533 md]553d.1 undcre dthuitthc Wilding
deo trot curre dy hew a uni m,Nn It is my mipotuihilit b notify as up.l of the
rc nimmcnta cmustw 'car issuenmotaccrtiRcsm of�c n Signature of Applicant Dale
o .nthnd'rcd.sent / 1 a All roof coverings to be Class "B"or better