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�iCONTRACTORAINFORMATION
BUILDING DIVISION PI RMIT
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CUPERTINO
KITCHEN DESIGNS
PERMIT"°.03090093
R'S NAME:
10562 S DE
ANZA BLV
PERMIT ISSUE DATE
L:.
(408)257-4900
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR DECLARATION
I arum that am hanxd under or Chapter 9 (commencingsI,
Job Description
ionhereby70 m Proona
l with Section 7000) of Division 3of Jlc Business am Prorcuium Codc. and my license is
in full rota and err ct.
License n _Lic,g , 6 63
j DataCumraclor /( O G
KITCHEN REMODEL
,
ARCHITECTS DECLARATION
es.
I
mMrsmndm aahall hat/ed as cords
a t'
v/
LncnxJ Pndcsmonal
OWNER BUILDER DECLARATION
j ON
C)
tired m Contractor's
I am exempt ram the Contractor's License Lew for the
1 Mrcso
i following rcomn. . (Section ]IBES. Business and Professions Code: Any city nr manly
which
which Permit 1
a mrmit to cnnatacl, altm impart, fie pair any etructerc
in aso h Permit 1
that he s I iaumcc. ass aint to theor. the
that om ending wJ pSection to the nr the Ch cmcnt
ovisio trtsof roe such Permit file a aL w (Charter
erY
Sq. Ft. Floor Area Valuation
of Doviorm
eBusinur'snd Professions Cox
i Oammcncingwirurra ft and nr basisu(,th the Busincatand PrarAny vi1.6do or
. mal he is em pt therefrom and me basin for me Any or
d acmant
35614063.00
l Pennon
oction ...cLsbe hundred dzntror a (S500mit aubjccts the applicant m,arll penalty Of
cta th to
not moa than five hundred dollars (S500). �- --'-
- �- APN
Number
.Occupancy
-Type -
0 1, as owner of the papeny, or my employees with wages as their side compensation,
will do Oc work, and the structure is not emended or offered for sale (Sec. ]M4, Bus'
and Pmfcmiaa Cmk: The Contrammr's List. law does not appy to an owner`or
iui
- d Inspections
property who builds or improves Orman, and whodoes such work himselfor through his
102
- PIERS
own employes, provided that such improvements are not intended moRercd for sale. If.
however,
1O3
— UFER
me building or improvement is sole within one year of completion, the owner -
milder will have tM burden of paving that M did not build or impowe for poryoa, of
104
- REBAR
este.).
y. contacting with to
I. as owner of the PrOSee
105
— ANCHOR BOLTS
7
the project Isms.]I3aa,wnerof and
, B sinnoivelynd j The Contractor's
The Con tractor's Li.
crow
1O6
— SEWER & WATER
La who hods or improves;
who conwdoes not r Such plytoan ith aofpropcny whosedpornttoContra,and
whocontractsLaw. far such projects with o contractor(a) licensed pursuant to tM Contractor's
202
— UNDERFLOOR PLUMBING
Li"rax law.
❑lam exempt under sec. ,e&Peter this ..an
203
— UNDERFLOOR MECHANICAL
r Data
204
205
— UNDERFLOOR FRAME
— UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
I hereby aRm under Nears or perjury am of the following xelana iom,
301
— ROUGH PLUMBING
Ihawand will maintain accrtrcatmofConsent to=Ir.innumfor worker,Coamn-
302
_
— TUB & OR SHOWER
tion, u provided for by Scel on Ira Of the Labor Codc. for the per(omrna of he
work for which thea pmrmit in Lund,
303
— ROUGH MECHANICAL
bate and will maintain Worker's Compensation Insurance, as required by section
3 04
- ROUGH ELECTRICAL
3]ta of the labor Code. far the perfmmancc of the work far which this Permit is issued.
305
— FRAME
My Worker's Compensation Insurance carrier and Policy number am:
3O6
— HOEDOWNS
artier:Zr�'fUNp Policy Na:000D ¢)D'2�3
2ERTIFICATE OF EXEMPTION FROM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
- SHEETROCK
or lmss.(rhtss"tim coed not he completed lithe mord, is for one hundred eollm($]a)
309
— EXTERIOR LATH
I certify that in the perfomunee of the work for which this permit is issued. I shall not
310
— INTERIOR LATH
employ any person In any manarr so as to become subject a the WorkmSCompcesation
Laws dC.Ii(m.i..Date
311
- SCRATCH COAT
APPlicant
313
— ROOF NAIL
NOTICE TO APPLICANT. If. after making this Ceniricam of Exemption. you should
became subject a the Workers Compensation pavisinns of the labor Code, you most
501
— FINAL ELECTRICAL ENERGY
ronhwi th comply with such Provisions or this Permit shall he deemed revoked.
502
— FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
Ihereby whichaffirm mat themman'I isacd(Sel. 3W7, ding agency lnnM perfurmancc esti
fur which this permis is issued ISec. J09], Civ. C.
504
- FINAL BUILDING ENERGY
Le dework
Lender's Name
505
— FINAL ELECTRICAL
Lender's Address
I aniy mat 1 have read this application and state that the above information is
506
— GAS TEST
comet l agree to comply with all city and county ordinances and state laws relating to
507
- FINAL PLUMBING
building construction. and hereby amhorim-Prceenmtives of this city 10 enter upon Ne
ahoy ed pmpeny, for inspection proposes.
— MECICAL
FIJaNG
(Wement) A
(We) agate to arty, indemnify and keep hamnlcss the City of Cupcnino against
liabilities, judgmmu,msta and mxpenses which may in any way accrue against said City
lin consequence or the
� 9
5
p
F&
granting of this Permit
APPLICANT UNDERSTAN 5 AND WILL COMPLY WITH ALL NON -POINT
REGULATIONS, 'y'S
Issued bSOUR
WORKSDate
laf�--
Re -roofs
signature of APpbcanucontracar D t
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will me applicant or future building meupant stow or handle harardous notional
as derned by the CuPmmnMunicipal, Codc. Chapter 9.12, and the Health and Safe,,
Section 25532(ap
.
❑tea No
All roofs shall be inspected
prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
haaamous air contaminants dcri d by the Bay Arca Air Quality Management
trim
all new materials for inspection.
❑Tcs IN
I have read the hmaNms mmcrialssequircomma under Chapter 6.95 of the Califor-
nia Hwlth & Safety Code. Sections 255115, 25533 and 25534.1 undrtsnand that if the huilding
it. not currently have a tenant that it'll my Marconi a nody the nerapmt of the
reyuirc nu which mustM 'rwiss ccofa Ccedfgte of Ore e.
Signature of Applicant
Date
it �'l Il O 3
All roof coverin PS t0 be Class "R" nr lint,,
Owner tar aoiho,i.d agent Dar„