05030200 CITY OF CUPERTINO
BUILDING DIVISION PERMIT * CONTRACTOR INFORMATION.
BUILDING ADDRESS: PERMIT %5030200
1411 T-TTZITERSTON PI_
OWNER'S NAME: PERMIT ISSUE DATE
E: - SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
a� 0 PLUMB MISCH
O O
M0 o LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
n� with Section 7")of Division 3 of the Business and Professions Code,and my licenee is
in full form and c@CL
jnz I-MMUMClns Lk.M ADD 499 ' (BED/DEN/2 BATHS)
tJ Dam Contracwr KITCHEN REMODEL
3
ARCH ITEused
DECLARATION
I understand my plans shack ed As public emards FEES, ADJUSTED/ TYPING ERROR/REFUND $639 .64 TO
3 sad Licensed Professional
i OWNER-BUILDER DECLARATION
0I I hereby.(Sce o n I e1.exempt(rens the Canuecmra License Law(m lk
loo follwhnwinpmsson.permit
7(1comment,alter. and ve.deoli Co de:Any em atcounty
u�$ which its asaapermit te,thspit WProve,doermitt firepsig.rayned ememcm
thtrbiuissusd Far ers torte thovisios,of ran each
antracmi's Limeo rile a,Law(Chapter
utemem
zFF< Natklncing wit Pucwanl to Me of Division
of the C Business and
(C Code)
Sq.Ft.Floor Area Valuation
S$ (cat he is exempt
with eceiome and the basis run of tie aged ca and ProAny vl CmkJ ter
3
that k h sumps therefrom and the ho0 far the alleged exemption.Any vlohdon of $65000
Section 7031.5 by soy Applicant for a permit subjew the applicant o a civil penalty of APN Number Occupancy T
not mem than five hundred dollars(5500). P y yPe
91,u owner of the property,or my employee with wages as deusom cwmpeeaallon,
1 do No wmk,and Ne untcwm Is not intended or offered for same(Sec.7044.Bouircas
and Profeselme Code:The Cenrrame is LI«nn Law dm not apply in an owner or Required Inspections
properly who builds or Improves lhemen,and whodeesa«h work himwlf or Waugh his
ownemployeas,provided that such improvements am notlnteMW meRemd for ala If.Innoweve /
Wilder the Wildingthe
rden of prent ovin1,veldwithinonsWeldofcermon,frtheowner-
"lllderwill have the burden of proving Nat k did lwt build Or improve(fir pumow Of
tele.).
1,u want of de,property am exclusively contracting with licensed centraners w
tract the project(Sec.7044,Busines and Professionalde:)CoTheCentracwr,U.
law sires not apply w an owner of properly who Wilds or improv Wmon,and,
who contracts for such prekcce with A co nescams)limnsed pursuant w the Conuactoes
License Law. Uy�%
❑lam extent!o"axes � � - .88 P/¢for is mss •/ /
owner Dam
617- W RKER'S SA ECLARATION
1 hemhy aEinn on natty of perjury We Of the(ellawingtions: T
haw and will mataain Ccniftau of C.meAthself-insure far orkees Corepcn- u/
on,u provided fm by Section 3700 of the labor Code,for One performance of W - (�
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.u required by Section
3700 of the labor Cade.for the performance of the weak for which this permit i,Weed
MY Woder,Compensation Insurance artier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EKEMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is far one hundred de0ara(gl
oaks) .
1 ser i(y that in the performance of W work for which this permit V iwood, all not
employ my pc 0 ymanner wmw me wbJesw n' pensnion
Laws of Califs
Applicmt
NOTICE APPLICANT:IL Ncr m N' en eau of Faempien•you paid
haeme mhJen w NC Worker's Cempc tion provisions of MMI
CndC,you must
.J z forthwith comply with tech prawn or Nis Pcrmiuhsil W d«recd mwkcd.
z y CON ON l.EN01NG AGENCY
[-r IWmbY affirm Natal naconswcsinn landin{agencyfor the perlormmceof
7i the weak for
which boa permit u sans,(Ss..3097,Civ.C.I
Cz lender's Name
�z Leaders Address
U0 I certify Out 1 have read this application And seem that the above information is '
Isr F eormet I agree w rnmplY with all city and county ordinances and men Is"misting w
C) building convection.and hereby amhodm representatives of this city w enter upon ft
W aW«-mentioned progeny for inspection Purposes.
(sec)Agra to III indemnify and keep harmless the City of Cu -a against
cn Iiabilitia,Judgmenu.cove endearments;which may in my way amseA lutuid City
U in censeq«nee of the granting of this permit
APPLICAPI UNDERSTANDS AND WILL C -PLY WITH L NON-POINT Issued by: Date
SOUR R GULATIONS/
Re-roofs
idfinned
A i r Date
H A DOU MATERIALS DISCLOSURE Type of Roof
WIII the app'am ter fuwm building mcupmuwm orhandlc hazardous material
by the upfrlim Municipal Code.Chapter 9.12.and the Health and Safety
.Section 25531(.)7 All roofs shall be inspected prior to any roofing material being installed.
Ya �Ne
Will the APPlicmt Or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Warman air contaminants As deflncd by the Bay Area Air Quality Management all new materials for inspection.
let?
❑Yes CK. -
1haw mad the hazardous ntauriel,requimntcnuunderCpipt A.9s ofthe Califor.
I.Has If, lyCoda3oNon25505.r5733and25534.1 nWdpern adthnifNc ilding
d«a rte ceras ly have A teams.that It la 1 mapomih yw nodi o«u t of
myuiIn me hkhmustbemetfarmA'w ban Or crcAO`/ OIVPVI Signature of Applicant Date
i
o' a urAuthorizedaSent Dam All roof coverings to be Class "B"or better
,� v