05010021 CITY OF CUPERTINO
BUILDING DIVISION PERMIT . CONTRACTOR INFORMATION -
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BUILDING ADDRESS: POSSIBILITY KITCHENS PERMITNO05010021
811 KIM ST
OWNER'S NAME: , - PERMIT ISSUE DATE
ANTHONY GRANERA 330 B LINCOLN AVE 01/04/2005
E:
SANITARY NO. CONTROL NO.
(408) 924-0204
ARCHITECTyENGINEER: l BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
uO0 LICENSED CONTRACTOR'S DECLARATION - -
w❑ hcmby affirm that l am licensed under provider Chapter 9(commencing- Job Desc 1 s� p(1`��
Zw with Sc ] Baf Divislon3of the Businns antic alk{{ ns Code.end myliccnseis TI � A'•�5.
<„ in
OHIO iteffect 8 KITCHEN REMODEL H YY ddd BLL��
j q 2 Liccn s, Lk.p S
O Da¢ o Conlrator o �n 1? [
ARCHITECTS DECLARATIOO[[!! MAR Iy ZGOJ
1 underidand my plans shall be used a public s dd, _
pyU
3 G t7, Licensed Professional p� p p B p PA B
` S OWNER-BUILDER DECLARATION - 'Q�(q�yq pp�I)/pt L as l}Clp``W9B
I hereby a?rte that 1 em exempt from Jm Contractors License taw for the
_00 following mason.Section
](DIS,Business and Profcasions Code:Any city or county
which¢quires a permit or comons ,alts,,improve,demolish,or mied,any structure 15000
prior to its issuerice,also require the applicant for such permil to file a signed stammenl
that he is licensed pursuant a the previsions of the Contractor's License Law(Chapm,9 Sq.Ft. Floor Area - Valuation
Fx
FG
(commencing xemitb Section andtfDi Was n 3
ofthe
eged Business andon.AnlORGMe)of
i�$ Nat he u exempt dacmfrom and the Ease for the alleged exemption.Any violation of -
Section 1831.5 by any applicant for a permit subjects the applicant o a civil penalty of e Occupancy Type
not mom Nan five hundred dollars(3500).
❑1,a owner or Ne propcny,or my employers with wages a theirsolc compenatian„
willd0 the wart,end the swnurt is natinunded oroRcrtd forsWe(See.]044,Business
and Reductions Cade:The Cmumemes Liarve n no
Law dot apply to an owner of '• - - Required Inspections
property who Wilds or improve thereon,and whodoessuch work himselforthrough his -
..conployen,provided Nal such improvements an,not intended oroOe,ed arsale.If.
however,the building or improvement is sold within atm year Mcomplefion,theowner- -
Wilder will have the burden of proving that he did not Wild or improve for purpose of
ale.).
D 1.as owner of the propeny,am.elusively contracting wilt licensed contractors in -
...t.CL the project(Sac.1044.Bosiness and Profesin.Code:)The Convecmri Li-
cause law don not apply to an owner,of property who Wilds or improves daemon.and -
whoconvactsfor such projects with a contractor(s)licensed pursuant to me Convanor'a - - -
LkaveLaw. .,
0 1 am exempt under See .B St P C for this reason - -
Owner Dale -
WORKERSCOMPENSATIONDECLARATION
I bemby affirm under parody of perjury one of the following drelaralmos: - -
0lban and will maintain aCertificate of Consent to self-insure for Workers Coupon. _ _
section,.pnevide4 for by Scetian 3100 of the labor Code.for the pe,m,ma,me of the
wails for which this permit is issued. ..
0 1 have and will maintain Worker's Compensation Insvance,as required by section
3100 of the labor Cods,for the performance of the work-f rr ch Nis permit is issued. _ - - - --- -- -
yWorkees<Cp�rjcns 'ofP�I,m'ura ea carrier and Policy n
Cartier. si't 's VN� Polish. ..
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ties..it...it not W complemJ if the permit is future hundraddullars($100) -
Mlcss.)
1 certify that in Ne performance of the work for which this permit is issued,I shall not
employ any Persian in any manner at as in become subject to the Woricers'Compensation
Laws of California.Dam —'— -� - �-
App[
iurl
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions or the Labor Chun.you most
.�Z foMwiN comply with such pravivions or this permit shall W decmed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-. 1 W mby af0rm that mem is a coaswninn lending agency for she performance of
yes 7 the work for which this permit is issued(Sce.W.Civ.C.)
Lenders Namc
z Lender's Address
V Q I certify that 1 basic read this application and state that Ne above information is
correct.1 agree to comply with all city and county ordinances and sate laws missing to 1
Q U Wilding construction.and hereby ambition mpmxnatives ofthis city to enter upon the /
}� aWn-mentioned prolmrty Tor inspection purposes
0. (We)agree to save,indemnify and keep harmless the City of Cupertino against _
Ff� Iiabilitiu,judgmcnla costs and expcnsu whichmeyinenyw yaccrvc aSainaaidCity
eanuquence of 6'on"' flhi permit
APPLICANT ERST ND WI O WITH ALL NON-POINT Issued by: Date
SOURCER
114,5
Re-roofs
Si um of Applicam/Con aur - D
HAZA ATERIAL SURE Type of Roof
Will the applicant or future building Occupant store or handle hmafd\ atenal
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
I .A.�
de.Section Z5324)? L! All roofs shall be inspected prior to any roofing material being installed.
Dy. Lino
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
il hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes1 have mad Ne hnnrdousmaterials myuirements underChapter 6.95 ofthe Califor-
Fiodc.Stttions 25W5,25513 anJ8534.1 undersand Net ifme Willing
st amamnsm,thaty as hilm molythceecupantnfdtcuim meo271-L• orac.NRcaseof ..panty. Signature of Applicant Date
OAC�� All roof coverings to be Class"B"or better
Owner or authonsJ age Date