03120081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC-°TORANFORMATIQN:"
BUILDINGADDRFSS: CUPERTINO KITCHEN DESIGNS FERMO13120081
%9n1AN1+M"ai!8PGRT 9R FERMrf ISSUE DATE
E: SANITARY N0. CONTROL NO.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t o o LICENSED AunderCONTRACTORS DECLARATION Job Description I NAL E® O
w I Mmby affirm Nat I am Bared under ponvolunuDECLARATION
A ION Y(commencing
i with Section- ]�d.r[Af Division 3af NC Busine�Pfofuva�Codf.gn liccnuu
'^ s+ in full fo d effect. Y//_Gtr 7G
I.iccnm Lle;• ADD 640 SQ. FT. / REMODEL l�/ 1.
a A CHITECT$ RATON 'DEC / 2004
As 1 uweruand my plans shall W used as public retools
0-u
3�� LiccncI encs Affir BUILDING
OWNER-BUILDER DECLARATION
aK I,Mason.
.Dien o n I a1.exempt Imre Fr Comms Co License taw for the
Ko 2 o fallowing reason.(Santora Ali L5,eosin=s and ere.de oli Cwc:Any city or roomy
a�$ which iMj,,.,permit re<nres thepilo,impmn,hermitt nrepair any menum
FZy pmr its issunnm,alsu requires applicant for such permit to File uigud sourer
C NelheisliecosedpursuanttotheprovisionsoftheConuator'sLicensetaw(Chapter9 Sq.Ft. Floor Area Va ua[ion
re (cammcneing with Section 20(0)of Division 3 of the Business and Profussiom Code)or
y that he is exempt therefrom and the basis for the alleged exempt em.Any violation of 1vk,,v,.{,
SmOm 7031.5 by any applicant for a permit subjects the applicant w a civil penally of 3.>'PN1rft#H;r0 0 Occupancy 1YPe
not more dun fin hundred dollars(5500).
❑1,asowner of Ne pmprny.or my employe=with wages u their sole compensadan,
w0ldo thi work.ead themucwm is not intended Wofremd foraalc(Sm.1044.Business Required Inspections
And Profeasiom Code:The Contactors Littre law deas raves apply to an owtror of 9 P
pmperty who builds orimpreav=Oarchn,and who doessuch wart himself orthrough his
own employers.prmided dot such improvements ac notinunded oroRcmd forvle_IL
however,the building or improvemem is sold within ore)ear of mmplcdon.Ne Owner-
builder will have 0u burden of proving that he did not build or Improve far purpose of
sale.).
❑1,as owner of the property,am exclusively convecting with licensed eonwcwrs to
convect de project(Sm.TOd41.Business and Professor Code:)The Contracwr's V.
cerise law does not apply m an owner of property who Wilds or improves thereon,and,
who contracts for such projects with o conuactor(s)licensed pursuant the Commetor's
License taw.
I am exempt under Sec. .B Is P C for Nb roman
Own= Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following doelaretionc
ban and will maintain a Cerufmcau of Consent to self-inaum for Workers Compen-
I
n,as provided for by Section 31110 of the Labor Cade,for the performance of the
for which this permit is issued.
haw and will maintain Workers Compensation Insurvim,as required by Section
of the Inbar Code.far the performance or the work for which this permit is issued.
Workers Compensation Insurance cannot and Policy number art:
cr. `�T �M7 pggttm'py'jao.: OOC'I l
CERTIFICATE OF EKEMpftONFROM WOR /�'
COMPENSATIO??ffINSURANCE
Oho sew=n reed not be completed if the permit or for enc hundred dollen(SIM)
aro Ices.)
I mnify that in the performance of the work for which this permit is Lured.I shall not
employ any person in any mannerso As an Wrome sobjcct to the Worlams Compensadon
Laws of Califomia.0.
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compewtion provisions of on,Labor Codc,you mora
,J Z fOMwob comply with such p rvisinm or this permit null M Maned revoked.
Z O CONSTRUCTION LENDING AGENCY r
Ihureby affirm that then is a construction lending agency for the pcoromunm of
GYi 7 the work sur which this permit u issued(See.3091,Co,C.)
W Q Lender's Name
Under,Address
VQ 1 cenify Nat I have mad this application and show Nn Oc above information I.
W coma 1 Igrte to comply with all city and county Artfulness and note laws claming to
building convection.and hereby muhmmine mpmaenutins of this city w eraser upon the
x{37 aWn-mentionw property rear inpccmion purposes.
IS. (Wm)agree to can.indemnify and temp harness the City of Cupertino again,
L.rq liabilities,judgment,costs and expenses,which may in any way am=againtsaid City / t
f>Z in conuqucnc"yr���,granting of this pe C.
^' APPLICANT/UNL RSfANfIS AND ILL LY WITH ALL APOINT Issued fs Date
SOUR R U ONS V\y n//��/�
Sgw.tu /pplicamicomtutor/pplic�aMContactor Oc Dau Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of ROOF
Will f applicant or future Wilding occupant tan or handle hwmdous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
wee,Section 25532(a)1 All roofs shall be inspected prior to any roofing material being installed.
0 Y=
If a roof is installed without firs[obtaining an inspection,I agree to remove
Will the applicant or um ildingmcupan Am equipment or devices which
.hawdou t air contaminants As dclond by dw Bay Arta Air Quality Management all new materials for inspection.
isoicR '
Dy. �U
I have rte a havmdnvmsm�alralscquimmenuundcrChapwr6.95ofthcCalifor-
niaHcalthhS ty we.5mdmu 25505.25533 and 255341.1 undershoot dot if Ne Wilding
docs notq.tth[�yn a wnanm Nat ire u mY mspanibilimy to potifY IW occupant oregaimmatixm t �a,facmdricau?Uf. q Signature of Applicant Date
Owneagent I,w All roof coverings to be Class"B"or better