05040002 CITY OF CUPER't'INO
BUILDING DIVISION PERMIT CONTRACTORINFORMATION'.-
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BUILDING ADDRESS: PERMIT NO.
DENNIS & JANET YAU 05040002
17C)'Z DR
OWNER'S NAME: PERMIT ISSUE DATE
.NE:
SANITARY G 9 64YROL NO.
ARCHITEC(ENGINEER' BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 o a 0
uoo LICENSED CONTRACTOR'S DECLARATION
w Ilurch,&from M.11 un licensed ander pmvisiom&of Chapter 91...end-& Job Deseripticiiji ppp n
4ik' with Bcction]IXN17 of Division Sof NC Businttuod Prufcuions COCc,aod myli¢nso is \ ' w rte®
in full force and affect. �p} / OA•�'-pt{,l kgµr'm�"
jt2? License Class/—�- 1) Licx 977 �' ADD 362 ' RELOCATE KITCHEN
Oam �pjp.,� Con —.- —
111
?cU I undersand my plansshallhe used 0as public records
0. Licensed Professional
- 2005
3 OWNER-BUILDER DECLARATION
E<f 1 haffirm Um I am exempt from the ConbacmLicense Law for the ® L®
p M.s.O following mown.(Section](ALS,Business and Pmre,vin^s Codwhich
Any city ar county
:s m which inquire.a permit m construct,alms,impmvc,demobh,nr repair any ssmcwrc p
y¢i poor to its issuance,also onuims she applicant for such Permit o file a signed smtement
< that he is licensed pursuant to Me provisions of the CommcmriLicense Law(Chafer 9 Sq.FC Floor Area Valuuon
xH$ (Commencing with Section 7")of Division 3 of Me Business and Professions Code)or
_ that he is exempt therefrom and Ne basis for the Jlegcd exemption.Any violation of
Section 7031.5 by any applicam for a permit subjects Me applicant to&civil pcnaltyof 3�er00 Occupancy Type
not mart Nan five hundred dollars(5500).
❑1,u owner of the proputy,ar my cmplayms with wage ss dc's sole compcnssuon,
will do Ne work and Ne structure is not intended or offered forsale(Sec.]044•Business
and Professions Code:The Comracmr's License Law doer not apply m an owner of Required Inspections
property who builds or impro es Memon,and who docssuch work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
howevea Me building or impmvcment is sold within am Pau of completion,the owner.
builder will have Mm burden of proving that he did not build or improve for purpose of
ink.).
❑I.as owner of Ne property,am exclusively contracting with licensed contractors to
coanmm Ne pmjcm(Sec.7044,Business and Professions Code:)The Comments.Li.
ceme law Coca not apply in an owner of property who builds or improves Merton.and
who contracts for such projects with a eonvactor(s)licensed pursuant m he Contractor's
License law.
❑1 oro exempt under Scc. ,B&P C for this moron .
Owner Date _
WORKER'S COMPENSATION DECLARATION
1 hereby Kinn under penalty of perjury ane of Me fallowing declarations:
❑I ham and will maintain a Carolinian of Consent to selGinsure for Workers Compel.
sation,az pmvidcd for by Section 37W of he labor Code,for Me performance of Me
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of Mc labor Code,for du performance of Me work for which this permit is issued
My Workers Comp adon lnsumna artier and Policy ruel"ram:
Carrier. y 3'Yfg Policy No.: l G l g a
CERTIFICATE OF E) MON FROM WORKER S'
COMPENS ION INSURANCE
(Thi.section need not hccomplem t dsic permit is fmomc hundred dollars($100)
or less.)
I comfy that in Me perrommocc of Me work rot which this permit is issued.I shall not
employ any person in any manner so as it become subjecu0 Me Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making Mu Cedificae of Exemption.you should
became subject m Me Workers Compensation provisions of the labor Code,you most
.J 0 forthwidt comply wif such provisions m this purmis shall be deemed mvnkcd.
Z"' CONSTRUCTION LENDING AGENCY
[-.� I heroby affirm that them is a construction lending agency for Me performance of
fY 7 Me work for which this pn of is issued(Sec.3097,Civ.C.)
d
L crdcr's Name t
=Z Lcodcrs Addmas
U O 1 certify Met 1 have read this application and sum that the above information H
U. ^P correct I agree to comply with all city and county ordinances and slam laws reading to
O U building Construction.and hereby aushoriae repmsentatives of Nis city to enter upon Me
T ILl above-mentioned property for impaction purymes
H 6. (We)agree to siva.Indemnify and keep harmless Me City of Cupertino against
h eiabili0es.judgment.casts and estimates which may in any way accrue against said City
U 2 in conseqummc of to granting of Mis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R ULATIONs.
0/01 Re-roofs
Signoreof Applfimac mncmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser fusion building Occupant mac or boodle hazardous ni mrial
az ddlned by Mu Cupenino Municipal Code.Chapter 9.11,and the Heald and Safety
Code.Sccuo^15531(&)
❑Y ? IS/ All roofs shall be inspected prior to any roofing material being installed.
Will Mea a t or future buildingOccupant sae a u. mens or devices which If a roof is installed without first obtaining an inspection,I agree to remove
\ it h.toms air com&minams u dedncb the Ba Arta A r Quality Marta nuent
r r r s all new materials for inspection.
District?
❑Yes 0N
I have nod Me hmmMmsmamrial.requiremcim under Chapter 6.95 of MC Calidm
ria Hc.10&Safety Code,Scetlom 15505,15533 and 25534.1 undersand dw done building
does not Currently have a mnant that it is my responsibility in notify Me&supra of Me
regaircmcros which most be man prior to ismanc,ora Ccmpcam of Occupancy. Signature of Applicant Date
�y
Owner or authomcd agent Doc
All roof coverings to be Class"13 or better
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