08020128 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT xCONTR'AC�T,=ORIN 'eORMATI N-,:
BUIL PERMrr NO.
QIreg'8R LA RODA DR KITCHEN WORKS INC/DBA 08020128
WNER'S NAME: FERMITIESUBDATE
MCFARLING RICHARD B AND DIANA 615 IRWIN ST 02/21/2008
PHONE: SANITARY NO. CONTROL NO.
(415) 456-4696
ARCHrMC(ENGINEER: BUILDING PERMIT INFO
BLDG BLECT PLUME MECH
30o LICENSED CONTRACTORS DECLARATION O O O
J U R I hereby affirm Nat I,m licensed under previsions of Chapter 9(commencing Job Description
withS don701g0ofDivision3afftOLWnWaM fcuinmCade.md-,Iie- ni, REPLCE 10 WNDWS & 1 BAY WNDW SAME SIZE, r rRPLC 6X4
^ F in full forte and effen
�gz taco CI 'L� Lie I �'p g WNDWS W 6X6 PATIO DR & ADD LIGHT & SWTCH
9 F, Dam Contractor .
ARCHf1EC7`S DEC ON
a U I understand my plana shad W used u public records
;t
c�a Licensed Pmfcaioml
b 3 OWNER-BUILDER DECLARATION
I hereby SIB=that I em exempt from the Con"Com's License Law for Ne
i p O following reason.(Section 70 I.5,Business and Professions Code:Any city or County
3� which equims a permit so emswct,alcor.impraw.mmnllsh,or repair any su em.
i�^ prior to its issuance,also requires tap appliesnt for such permit m rile a signed stammern -
< that he islieneW nt m the n pursuaro provisioof the Contractor's License Taw(Chaptu9 Sq.Ft.Floor Area Valuation -
�9 m mmencingwith Sccdon7M0)of Divlsion3ofthe Busip udPro(essinu Code)or 528�0�
`<— that he is exempt therefrom and the basis for the alleged exmpdon.Any violation of
Section 7031.5 by arry applicant for 4 permit subjects the applmanl m a COR penalty OfNumber Occupancy Type
not more than Bw hundred dollar,($500). 3 6 9 3 3 012 !ff
0 I:Sa owner of the pmperty,m my employees with wages as their sale compensation,
will do the work and lheanuctme is not intended or offered rot sale(Sec.TOM,Businoa Required Inspections
and Profc smns Cade:The Commutes LicuuLam e
e w does not apply an Owner of q P
pmpeny,who builds or i mpows thermo,and who docs suc h it himml f m through his
own employers,praHded WI such impmwmenu ate not Intended aroRerM fmsale IL
nonacm.the building or Impmw sou is Sold within aro your ofempletian.the owner. .
builder will have the burden of proWng Wl W did ter build or impure for purpose of
Sam.).
0 1,as maser of the property,am exclusively contracting with licensed conawcmra to
comroct the project(Sec.70M,Business and Professions Codo:)The Convectors U.
come Law dace not apply m an owner of property who builds or Improve flumen,and
who concocts for such projecm with aconmcmr(U licensed pursuant to the Conlrxtors
Lm um Law.
O lamuemptunder See ,B&PCfmthisreawn
Dam
WORKER'S COMPENSATION DECLIRATION
1 hereby Siam under Penalty of perjury one of the following declarations:
0 1 have and will maintain,CenifiuM of Conunl m xlGlnsuro fm Workers Compm
Sation,an provided for by Section 37M of the Labor Code.for the performeoce of the
work for which this permit is Issued.
0 1 lura and will maintain Worsers Compensation Imuran¢,as required by Section
3700 of the Vwr Code,for Ne performance of the work for which this pemsil H issued
My Workers Campnexama mate.canim and Policy number ere:
clerics.rTiA L PolicyNa.: /.l7—eo�0J(n
CERTIFlC—A4 OFEXEMPION FROM WORKERS'
COMPENSATION INSURANCE
(nds section need noted complemd If the Permit Is fmone hundredmllars(SIM)
Or lux)
1 certify Net in the perfomaxe of the were for which Nis Permit IS issued.I shall nal
employ any person in any manncr.as in becoma subject to the Worle rf C.Opsub,•don .
Laws of Glifixem.Dam -
Applicant
NOTICE TO APPLICANT:IL anor making this Certificate of Exemption,you should
become Subject N the Worker's ComPemeadon provisions of the Utor Cede,you most
.JO forthwith comply wit such provisions or this permit shall W deemed revoked.
Z0 CONSTRUCTION LENDING AGENCY
ti
F Iedr which m that NemhnCo (Sm.3n lending agency for the Performance of
W' the wen's for which Nis permit is used(Sm.J09'y,Civ,CJ
A [coders Name
� Z Lenders Address
U O 1 unify but 1 haw read this application and SUM that sed show in(om,tien M
COMM 1 SUMM m Comply with all CITY and County aNinanee i and SUM IS"relating N
Wilding construction.and hereby Suthotlxe rtpuentaflWn;of this city On enter upon the
W above-mordoned property rot inspection purposes
956 IWO)agree to Saw,indemnify and keep harmless tap City of Cupertino Spurt
F fly liabilities,judgments.casts and expenses which may In any way xcruc gLWdl said City
U Z in Cornequance of Ne granting of this Permb.
^ APPLI UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2
SCUMREGU 0
Re-roofs
Signature of ApplEmmuszontrasemer Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuwm building occupam Shm or handle havvdous mamnal
as de0ned by the Cupnim Municipal Code.Chapter 9.13,and me Health and Safety
.Section 25532(.)7
❑Yu. @ LLo All roofs shall be inspected prior to any roofing material being installed.
Will the appikert ar IUMIC wilding ompsm um NO!Poland or maces which If a roof is installed without first obtaining an inspection,.I agree to remove
emit huurEm nair conumimnu as derined by de,Bay Area Air Quality Management all new materials for inspection.
DUricl7
CYu
1 haw real the hundr a✓materials requirements under CMp cr6.95 of the Califon
nice Health&SafetyCode,Scetions 25505,25533 and 21534.1 understand that if the wilding
does ml c ntlY ... the mY rtapossibility m notify Ne occupant of the
OxIO whichmuaMnml,mm issuaneeofa Ccrtimam of Occas Y. signature of Applicant Date
Owner or wNarixd qcm DaM' '
All roof coverings to be Class"B"or better