04110005 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT �=C01S(TRAGT0RjNFORMA�ION
Efi vMIG>1FF a.<.Y d'vz,..A 3. '�.& a.'§3f2
BUILDINGADDRESS: - PERMIT NO. - .-
A-1-DESIGNS 04110005
367 �IRNRY CREEK PL OWNER'S NAME: PERMIT 65UE DATE
E. SANITARY OL NO.
AR CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
-u00 - LICENSED CONTRACTOR'S DECLARATION Job Description
y w❑ 1 thereby afprm that 1 am licensed andp�rovisumr of Chapter 9(commencing _
U with Section]pyJ)orDivi'on 3ofthc Businr�N.and Profoa ioas Codc.endmylicenecis
in WIY(waan daffect.
qz ucenmClE L .a' �F�3Z� KITCHEN REMODEL -
F Dau: Contractor _
ARCHI'IECrS RATION
'� < 1 unacrsunJ my Plans 11 W p records - - -
3WG Licensed Professional j
g OWNER-BUILDER DECLA TION
+� I hereby,(firm Not I am exempt from the Contractor's License Law fur the
. p o ficH.M.g rowan.(Su6.n 1W 1.5,Busincssand Professions Cade:Any city er county - -
m which require a permit t.cwwruc6 abmr,impur e.demolish.err repair any stmcure --
:ziprior mics issuance.also require the applicant for such Permit to rile a signed statement aa''��
Nat he is licensed pursuant to she provisions of the Contrxtori Ilan Law(Chapter 9 Sq.Ft. Floor Area (:511010on
ceFo (commencing with Section 7")of Division 3 or me Business and Professions Code)or .. J
y $ that he u exempt therefrom and that Innis for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit momeu the applicant m a civil penally of. 3 4..k.eO 0 Occupancy Type
not maty Nan riw hundred dollen r$!iNB. YY
❑1,n owner of she property,or my employees with wages as their sole compensation,
wild.the we rk and the swnurt is notinunded or pRered forsale(Sa.]044,Busimss
and Profession Cade:The Contractors license Law axe not apply m an owner or ...-. Required Inspections -
propatywhoWildsorimprowsthereon.and who deassueh work himselfor through his - - - - --
ownemplM ee,provided Nat such improvements are not intended impletion.for owner.
however,Ne Wilding or improvement oawmcnt is mid within arc]ear of completion.Ne owuer-
.It.).r .wiB have du Wrden of proving that he did nos Wild or improve for PUNox or
sale.).
❑h as owner of the property,am uclosiwly contracting with licensed Convectors to
emouract she project(Sec.Rl44,.Business and Professions Code:)The Contnemr's Li-
cense law Coes not apply to an owner of property who Wilds or improves Merton,and '- "'---- '------ ---
who contracts for such projects with a contranor(U licensed pursuanuo tW Commicthrs —
License Law.
0 l am exempt unaer Sec ,B&PC for Mi..•..a -
owner Date
I
WORKER'S COMPENSATION DECLARATION
V1 hereby aRnm under penalty of perjury on of Ne following declaa..ns:
Vto
and will maintain,Cenifmam of Cement to self-insure for Workces Compcn- -,n proviaca for by Section 3100 of Ne labor Code,for the performance of Ne
far which bar permit is issued.
haw and will maintain Worker's Compensation InsWana,az myuircd by Section of ire Labor Cade,for Ne poformance of Ne work far which this permit is issued.
WOmkc 0. or Insura carrier and Polity numberr. Pal'
CE IFICA'fE OF EXEMPn R( WORKERS
COMPENSATION INSURANCE
This section need nos W completed if the permit is for one hundred dnllars RI011) -
orless.
I certify that in the performance of the work for which this permit it issued.I shall am
employ any person in any manner so as in become subject to thc Workcas Compensation
Laws of California.Data _ -
Applicant
NOTICE TO APPLICANT:IL after making this Cenificau Of Exemption,you should
become subject to the Worker's Compeatmion pmvisions of the Later Cade,you muss
7Z fpMwith comply with Such prim,mnns or this permit sMll he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F-' I hereby anions thin them is a conswction lending Proe far the per(mram.of
the work fur which Nis permit is issued(Sec.3091,Ci,C.)
QLanders Name
Z Lenders Address
U 0 1 certify Nn I haw mad this...licadon and radio that the aWw information is
t" cancer.l agree m comply with ail city and county ordinances and sure taws orbiting to
D V building construction,and hereby authorim mprescrodws of this city in cider upon Me
4 ah.vcmcmioncd propcny for inspection purposes. /
(•-' (We)agree to mw,indemnify and keep broadcast the City Of Cupcnino against
h liabilities,judgments.cos%and expenses which may in any way see=against raid City
U z m conxyucnee of the gaming of this permit.
APPLICANT UNDERlTTANDf AND WILL COMPLY WITH ALL ON-POINT Issued by: Date -
SOURCE REGULATIONS.
J- -- Re-roofs
Si naurcof Applicau marmsor Dam
HA2 ARDOUSMATERIALSDISCLOOSURE Type of Roof
Will the applicant ter future building occupant more or handle ha�ous material
az defined by the Cupenino Municipal Code,Chapter 9.12,and she Health and Safety
c.de.settinnkQ
2ss3z(a)? [�N. All roofs shall be inspected prior to any roofing material being installed.
�Ycs
Will the applicant or future Wilding occupant tea equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
it hazardous air canuminanu az defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 haw mail Ne haardn is materials requitemcnts under Chapter 6.95 of the Califor-
aiaHcalth&Safety Coda,Sccaom255f15.25s]3md25534.1 undcrsmnd thaif the Wading
docs not currently have a mnanL Nat tis my responsibility m nualY drt weupant.f the
Wmcap�hmua Wmet pri= to ora cenifiemtfa.opaney. Signature of Applicant Dateits,
owne or onvcaapent ` Date
All roof coverings to be Class"B" or better