06050113 CITY OF CUPERTINO
BUILDING DIVISION pET "��
BUILDING ADDRESS: r SEARS `HOME IMPROVEMENT PERMIT NO.06050113
22684 LIBERTY OAK LA
OWNER'S NAME: PEPMITL'SUEDATS
ROSE MARY GREENE 283 E. AIRWAY BLVD. OS/12/2006
E: SANITARY NO. CONTROL NO.
(925) 245-2000
ARCHI TECT7ENGINEER: BUILDING PERMIT INFO
BLDG lam . ELECT
� t� 0
iC j LICENSED CONTRACTOR'S DECLARATION Job DeSCilphOn
1 1 wroby affirm that l Am licensed under provision of Chapter 9(cemmcaln{
atj with Sudan 7")ofDi,Ismm 3ofden Business aha Professiom Code.admy Be..,..
�h
I.fall force And eff RE-FACE KITCHEN CABINETS/INSTALL NEW COUNTERTOP
'n? Dau f�Can ucmr RECONNECT NEW SINK AND FAUCETS . NO ELECTRICAL
M�� ARCHITECTS DECLARATION—
1 understand my pima shall w iced u Public rearm
a Inc. Licensed Pmfeuional
b0 OWNER-BUILDER DECLARATION
I knotty AIR.that I Am tempt from the Convenor's Licane Law for the
O O following mann.(Sudan 7031.!.Business and profession Code:My city or County
3 3� which mgMres a permit In eanwuc4 aim.Impmw,demolia,or repair any smeture
zSm prior At its issuance,also requires lhcapplicwt forsuch Permit to Me a signed atatemmt
c that he is licensed pursuant to the povislOnofthe Conuactur'aLimmcLaw(Chapter 9 Sq. Ft. Floor Area ValuaNrQ
(commma.if with Section 7000)of Division 3 of dm Business and Pmfession Cade).1
y g! 'hat M 4 caempt therefrom ad use bale for the alleged eaemp lm Any violation of
Section 703L5 by ay appllant for A permit wbjecn w a9plicam In a Civil Penalty Of y y type
nuc n Bw an m'hahundred dolwa(S300). 3'FA��1 T 0 0 Occupancy
❑1,n owwr of the property,n my employm with wages u dell me amPertaada,
will do thework.and luxuruma Is natimended or offered Amato(Sec.ION,Business Required Inspections
and eny.h leu Cade:The Communescam,ad
Law don rot apply a an owner of q ��
property to a bulldaserireprovesch imps and ww romasuchadal ar ass edthrough his
own e .ducm,dig ar ImaseAntisawmenuareletIewofcWaRued for ale V•
bawew;Ne wilding W ImprovementisAmid twithin am year or mmpWin.the ownu-
AsNALE
k.)r will Save dm worm of'roving Nat K did rot wile or improv for puryase of
au.).
[31,As Owner of the Property an exclusively contracting with mmnaed mentraters to JUN
comma the preen(SCA.70".Business AW PrOfaYan Code:)The CamV CtOe3 U- _1006
ase Law does not Apply tom awns of property who bullet or Improve mann.and.
License acv far tush pmkas wlthamnvwtWp)0celued punuammlha Contractor's
License Law.
❑Imaempl under See .B&PCfar Wls mown M �J
nu Dau l7�
WORKERS COMPENSATION DECLARATION
I mmby alflm under penalty of perjury one of the fallowing declarations:
❑T haw and will maintain aCadOeste of Comenteself-Wram fW WWker'aCMPa-
adM.a provided fm by Section 3700 of the LOW Cade.for the perfomam Of the
wort for which this Permit is mood.
❑1 haw ad will malnum Wark es Compensation Inursme,As required by Section
3700 of the Tabor Code,fed the perfamace of the work for which this permit Is lamed.
My Work1er's�Compensation I�nwcaee arrier ad Policy number ate:�
Camfwr.W�N Ci3 Policy No.WtRCI&W
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE v
mils section mad wt w completed]film perk Is frrone hundred dallan(11100)
,It lea)
1 artery that in Ibe Performance of the work for which this permit 4 Wood.I shall set
Ampules,aypcoun in Any maters,As In became subject to the worFui COMPenaauw
Laws of Calif.rors.Dam -
Applinat
NOTICE TO APPLICANT:If,after making this L'eriMlate of Exemption,you should
become abject in the Worker's Computation provisions a the Laver Cada,you mall
OfaMwim comply with such provision or this permit shall w deemed revalued.
'Z' CONSTRUCTION LENDING AGENCY
^
[-' I hereby arnon that dere Is.ConmWtion lending agency for the pmfOmAncc of
ai > the wink for which puts peri'ls Wood(Som.3097.Civ.C.)
QLender's Name
.7 z1:6 Lender's Addms
U O 1 unify ren I have rod this application and sate that tw abet information 4
Ile l'" comcct.1 a&=to comply with all city ad county ominous ad auto Ian relating m
U building Conwuction.and hereby authatiu reprevenutives of this city m Amer upon tie
�U above-mentioned property for inpecuon purposes.
Lis (We)agree to saw,indemnify ad kap harmless the City of Cupertino aLains'
rA Iiabllitia.judgmenu,emuandexpenn which mayu army aarme Apinfaid City
U z in eamegwme orthe{nndng of thin pemiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date i/2
SOURCE RECULATI�
Ste/ 6 Re-roofs ��--
SI{nuurt of Appllesn onRDO Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ft Cu pert Wfuturebuilding aaupwtnom seradth Health hazardous material
As defined by tie Cupenina Municipal Code.Chapter 9.13.ad de Health ad Safety
ode,Scala 2533:(,)7 All roofs shall be inspected prior to any roofing material being installed.
❑res ❑Na
Will ft appllcat or future building occupant on equipment or devima which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaMnus air comuminants As defined by the Bay Ma Air Quality Management all new materials for inspection.
Claim? .
❑Yes ❑No
I haw card the haardws maurialsrequhemauader ChiNW6,95 efthe Califm-
ata Huhh&Sarayeada Swa6ma25303.25333 aha 25334.1 andersund mauve wilding
data not Curmntly have a tenial Nat It 4 my reapemibillly m notify the Occupant Of the
ratio et�accmnae_oa�.� Signature of Applicant Date
Ownerse�thomed-atgem ° Da: All roof coverings to be Class"B"or better