05040067 CITY OF CUPERTINO y a ,aR+z as r�r Ir)*�+af+�' .`
BUILDING DIVISION PERMIT CONTRACTOR I 'URMA'.CIONf
.,'*s.4fl ti, .
BUILDING ADDRESS: •HAMMOND CONST PERMITNG05040067
OWNER'S NAME: PERMIT ISSUE DATE
IE: SANITARY -CONTROL NO.
ARCHITECTIENGINEEN: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�am6 LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing P
with Succ..7M)of Divlalm 3 of the Business.0 Profe+siov Coda.and my liceroe B
n i
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foil —f 38 �n2 aicauseassn -L LwKITCHEN REMODEL
EPZ51,04lf Caacwr
T.uSa: *i e
e0 ARCH l he use DECLARATION r/
y I understood my plena MSII he used an public rtcnrdS a'Ng4
Licensed Professional JAN N
owNEm axe DBR DECORATION A
5E I mono .(Sero on 1 1. exempt from the Cmntanm Code:
License Law for Ne
S:0 0 whichfollowing roumu(Section 7W LS,Business and Improve,
de nv Coon:Any city or county
$ which Ryuima a pump ac cores; t,alar,improve,de ermit t or e a sir my structure
pdmwiaiensedp aimpursuant
acquires;ter applicant o for wesochpennitw Neasigncduawment
<
thin memin lei PS antwlhcProvidmofowConnecter'+Id tulaw(Clupur9 Sq.Ft.Floor Area ; b• Valu on
(commandng wide Seefrom nd)th D osis far
th the egad exe and on.AS,vi Cnde)m s e.'z
BB Net la Is attempt therefrom and the pear fu dx subjects
due exemption.in Any l violation of ken}
Section 71131.5 n any applicant for a pemit aubkcu Ne applicant w a oval penalty of 3 6'4T3`l1>9*91D 0 Odblypancy Type
art meg that Bve hundred daltan(SSWL
❑1.u ower of tic property.a my mploym with tense u ftirmieampemdan,
will do Newark.end thesmuctwo unm intended earoRcRA forWe(Sec.70a/,Budnw Required Inspections
and Profmione Code:The Con axon's Liam law does not apply w e an owner of q P
propeny who builds or improv desmon,and who doss such work himself or through his
man employees.provided that such Improvements are not inunded oroQered fe rnaw.If.
bowew.the building or Unprovernem Issold within arc Year of ampledon,dee maser.
builder will now the burden of paving Nat M did rot hold or improve for puryoac of
SAM.).
❑1,see owner of the property,am exclusively eonuacdng with licensed contractors to
contract the project(Sec.7044.Businm and Profeauov Code)The ComracmM1 Lb
4C37]�11
law don not apply u an owner of property who wi1N or imProw Norton.sed,
contracts for Such prejeew wide a conuennr(s)licensed pursuant w the Contracwra
se Law.
om exempt under Sec. ,B&PC for this reasoner Das
WORKERS COMPENSATION DECLARATION
I Mwby affirm under penalty of Perjury ane of the following de lummax:
ham end will malmaln•CerdOcale of CmwmLto self-InwmfmWmkeriCompen-
n,u provided for by Section 7700 of Ne labor Cade,fm the P rformance mf dofor which this Permit ta issued.
haw end will maintain Woskeri Compemtion Insurance,u respired by Section
of the labor Code,for Ne performance of the work for which this permit is laxed.
My WortrYS Compensation
.Inmr`aa carrier and Policy number all:
carrier. Policy Na: I y 7 00
CERTIFICATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
Cihhuction sed not w completed if the permit is fsonchundrod dollars(51110)
of hula)
1 anify that in the performance of Mc.,it for which this Permit Is issued.I"I not
employ any person in any mannerso As to become Subject o now Workers'Compensation
Laws of California.Dau -
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Should
become Subject to the Wortets Campemuon pecremons of the lather Code•you muse
z Forthwith amply with such provisions;u this Permit Shall no deemed Rwtrd.
z O CONSTRUCTION LENDING AGENCY
F I hereby allim that Vert is a construction lending agency for the performance of
C? Nc work for which this Permit u issued(Sec.7071.Civ.C.)
WQ laude".Name
z Lemires Addmas
V Q 1 ocnify that 1 haw mad Nin appliation end mute Net the above wilmmadon is
14 cornea I agme in comply with all city and county ordwonaund sou laws Rlating to
O building anstroctien,and hereby Authorize rtprtxnudw of Nis city w enter upon Ne
W awve mentioned properly for ivpecdon pugwua
f5. (We)agree w sew•indemnify and tree harmlessder City of Cupertino against
fq lubilldes,judgmenu,coSu and expenses which may in any way accmc a alnstsaid City "
U,'� incouseepamccoftheSnudiagafthis
t-•' APPLICANT R ANos A WILL COMPLY W N N. INT Issued by: Date
SOURCE RE NS.
Re-roofs
Signe of ApplicanUCmn r Dow
-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or too=building oo upam more or handle huallous mwoul
as definedthy Ne Cupenino MunM I Code,Chapter 9.13,AM der Haled and Safety
Code,Section 25532A)? All roofs shall be inspected prior to any roofing material being installed.
Cl Yes 10
Will the applicant or fuum wilding occupant m equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air eoutaainRs As acd by the Bay Alla Air Quality Manageorml all new materials for inspection.
isxict7
❑Yes
I haw road the Maanlousmtwriabuquiremenu under Clupur G95 of the Califon
nu HcalNkSafdy Cmdc, .25505 I3wW2553a.IYrdarsardduUfdw kidding
does not cu ant,dh my"M nit der oce antuf Na
roqulrerpri also rwiuuuraoGCelrifle: of�ucy. Signature QfApplicant Date
r unmhovW a t l/// •3Daw All roof coverings to be Class"B"Or better
C