04120079 (2) CITY OF CUPERTINO '�•- a '� %'''
BUILDING DIVISION pI;R�I' CONTRACTnR
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BUILDING ADDRESS: CUSTOM KITCHENS & BATHS PERMIT No04120079
21408 KRZICH PL
OWNER'S NAME: PERMIT ISSUE DATE
Ak BABU NOTT 581 CALPELLA DR 12 /1 -1 /2004
ZONE:
"--' SANITARY NO.""" 'CONTROL NO.
(408) 829-0078
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�a0o LICENSED CONTRACTOR'S DECLARATION ?Jab 8s ription
m C wt hereby affirm Wat I am liccnxd under provisions of Chaplcr 9(commcncing `. It'$w`i,, Iva
iw lion],Y ,a rvixion7oflM Busircss aaM Professions Godc,a. myliccnu is Itll�IHnl lkllll\\MV1!]lt(//a(��-aC\91pFIIL^94rL15�ID
'„ infullf nderrea - ✓Y oj6t� BATHRM REMODEL
z LiWase Class Lk..
Date Z� Contractor
ARCI DECLAR ds tlG� IOJ 200[
�i < n clan of h as public records !'GA I. J
a� Leek �����81�
S OWNER-BUILDER DECLARATION
1 hereby afRrm that I on exempt from the Ctunbamars License Law lar the
'0 following mason.(Second](D 1.5,Business and Professions Cotte:Any city or county
x m which requires a permit to consumer,eller,improve,demolish.or repair any awcture
m poor o its issuance.also requires the applicant for such Permit o file a Signed statement
that he is licensed pursuant to the previsions of the Contractor's License Law(Chaparr 9 Sq.Ft.Floor Area Valuation
mFo (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i
that he is exempt therefrom and Ne basis for he alleged exemption.Any violation of
Fection]031.5 by any applicant for a Permits flipms the applicant to a civil penalty of er0 0 Occupancy Type
not mom Han five hundred m1hura(SSW).
0 1,as owner of ilm pmpeny,or my employees with wages as their ole compensation•
will do the work,and the structure is not intended as offered for sale(Sec.7W4,Business
add Pmfessi.ns Code:The Connector License Law does not apply to in owner of Required Inspections
property who builds.,improves Hereon,and who docssueh work himself.,through his
own employees,provided that such improvements are not intended or offered for sale.If,
however.He building or improvement is sold within one year of completion.He owner-
builder will hags He burden of proving that he did not Wild or improve for compost,of
sale.).
❑Las owner of the pro cony,am exclusively contracting with liccnxd cmdenctos 10
conswet He pmject(Sec.7W.Business and Professions;Code:)The Contracmi s U
cease law dors not apply to an owner of property who Wilds or improves Hereon,and.
who contacts for such projects win a wntnetods)licensed pursuantto He Contractors
.L aLow. ! ,
�es bit P
& Cf.r His,cason
Own
1�. WOMEMSCOVILENSATIONDECLARATION
I hereby affirm under penalty of perjury ane of the following declarations:
0 1 have and will maintain aCenificateof Consent to self-insure for Worker's Comma-
added.az provided for by Section 31W of He labor Code•for the performance of He
work for which His permit is issued.
0 1 have and will maintain Workoi s Compensation Insurance,m required by Section
3100 of the labor Code,for He pedo...of He work Tor which His p.it is issued.
My WorkeYs Compensation Insurance caster and Policy number aa:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not W completed if be .it is fortune hundred do]].S Lor? -
or less.)
1 certify Hnt in the perform o the work for which this permit is issued,1 shall nut
employ any person in an5ytfenxazo ccm2 OWL to the Workers'Compensation
Daws of Calif. i c
Applicant
NOT E T / a g this Certificate of Exemption,you should
Mcome fen m the Wdrkm's C.mpc tion previsions of the labor Code.you must
.JO fo comply with such Provisions or His permit shall Wdeemed revoked.
Za CONSTRUCTION LENDING AGENCY
t-r I hemhy allim Hat them is a construction lending agency lot He icrfu,mance of
Q: > Ne work for which this permit is issued(Sec.3W7,Civ.C.)
V] 4 Lender's Name
G Landers Address
VQ 1 certify Hat i have mad this application and some that the above information is
r Woret.l agree to comply with all city and county ordinances and scam laws retatingte
0O building construction.and hereby authoms repreecntatise of His city to enter upon the -'
Y' above mentioned pmpcny for inspection Purposes.
0. (We)acme on save,indemnify and keep harmless the City of Cupertino against
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liabilities,judgments,costs and improver which may in any way accam against said City
V z APP CANT UNDEof the RSTA gDf thsNO,WILL COMPLY WITH AI`L NO Issued by: Date I '� r ✓
CSOURC S.
d Re-roofs
Si9naLclrFqAp,TicrnVConuraMr ^" Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stole or handle hmardous mammal
as defined by the Cupertino Municipal Code Chapter 9.13,and He Health and Safety
Code,Section 35513(x)7 All roofs shall be inspected prior to an roofing material beim installed.
❑Yea N. P P Y g g
Will the applicant or future building occupant use Wd,mcntan devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harmdoos air conmminanu az Jgkmd by the Bay Arca Air Quality Management all new materials for inspection.
District?
0 Yet
I have read the harardnus materials requirements under Chapter 6.95 of He Califor-
tax Hcalth&Saday Code,Smdms 255115.25533 and 35534.1 undesund that if rte Wilding
Jas not cuneml sae a tenant Ha4ia resp ark, it by t n.uf y rte a,cupanl o[He
ric'm mm c t dor ancenfa l IOaopBy(`(/ Signature of Applicant Date
ow t ,ed a Dam All roof coverings to be Class"B"or better
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av CITY•OF CUPERTINO 6V2- cr, 7 9
CITY OF PERMIT APPLICATION FORM /
CUPERTINO
APN # Date:
iz- X3-0'/
Building OAddress: L Mailing Address (if different from building address):
Owner's Name: Phone #:
Comes,`r Q S License #: S 7
(� G
Contac Phone: Cupertino Business License#:
S Fax:
Building Permit Info:
Bldg ❑ Elect 9--� Plumb [�, Mech L�
Job Description:
Residential 2/ ee Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Proje t: Occupanc roup:
>�S'pvb .
Type of Const ction: Pleas check-tis box if t project is a
• secon or additiwr Li
Project size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOiLER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
® BINVESTIGA Investigation fee BUILDING
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