04050148 CITY OF CUPERTINO '� r 77-7-7-77777777777777=,W '7e
BUILDING DIVISION PERMIT CUN'T1tAC'i'URT1+i .f3RMATON
BUIL DING ADDRESS; BASIC CONTRUCTION SERVICES PERMITND04 050148
736 LINDA VISTA nR
R'S NAME: PERMIT ISSUE DATE
ROBERT & JUNE PAD DICKENS
E: SANITARY NO. CONTROL NO.
(408) 369-0257
ARCHTIEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3GDz LICENSED CONTRACTOR'S DECLARATION Job Description
0 1 hamby i Irian that 1 am Inimical under pmvisioiu of Chapter 9(commencing I3
n� with Section] )*(Division Sof due HusipC/Iand Pmfexiune Code.and mylicenx is
in fullfo c mt. ✓ —j '3\ REMODEL--KITCHEN & BEDROOM
p�z Lk Llc.e
^�O
Co.Y.I1Lr
ARCHITECTS DE lATION
I understand my phm shad W used a public rocionas �xC
,6D
o Licensed Pndcssinnel
5
OWNER-BUILDER DECLARATION
Cimm ON /f
E t hereby.(Bone that 1 L uempt from the Cssiom Code:Any c Law for the
p0 which
following reason.(S.I,t 703L5,BusinessandRefdcoudih.oAny city or county
$ which erqulua Issuance.Stan re mmwe alter.improv,ec Permit
t or repair any structure
tharm its ensed .SnLto sea the applicant Of for such pcmiuoieco.Lw(a signed suxmem
mma ((commencing
om ecce withSection7 )ofDiviomoftiteConuacmr'ani¢nxlaw(Code)or Sq.Ft. Floor Area ®� Value Ion
sF$ that anis amwilt Section7")of DivisiofreflWeged couanal Professions Code)or ,
Net ha u exempt thert(erm mal six buffs far six alleged eump0on.Any vlols0on of ��rs'�m ®, r%
Section 7031.5 by any applicant for a Pemdt objects the applicant m a civil penally of 8'QWn1ber0 0 QccU nC Type
not more Nen five hundred dollars(5500), y '7 p
❑I,uowmrofftpmpeny,ormyemploycuwi0mguudxirmiccompenrallon,
will do th*woalt and thaavuctum is not intended oroQered fertile(Sec.]Odle,Business
.it Pmfesslou Code:The C*nuacxYs Liaise law does not apply to an owner of Required Inspections
propenywhobuilN orimprowa thereon,and whodmssuch work himae fordurough his
own employees,provided that such improvements art not intended moQered forted*.If.
however.the Wilding or improvement is Sold within one yea o(coo pledon.the owner-
bullder .will have the huNen of serving that be did not build or Impruw,for Portae of
isle.).
1,u owner of the property,am uclusively conhuting with 1lceved contraction;m
construct the project(Sec.7044.Business and Professions Code:)The Comsutofa Li. .
ceue Law docs not apply in an Owner of property who Wilds or Improw s thertun,and
who contracts for such projects with a conuumr(s)licensed pursuant o the Contractors
License law.
I am uempt under Sec. .B k P C for Ihu uaun
r Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury ane of the following declarations:
1 haw and will maiotsin a CeNricax of Couu
enoself-insure for Worle rSCompcn-
S on.u onvided for by Section 3700 of due labor Code,for the perfmmance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
370D of the la Wr Code.for the performance of the work for which this Permit is issued. .
My Wer Comte mi rantsurricrand Policy Wr au:ge
Cartier. — Polity No.: sT o
CERTIFICATE OF EX MON FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not he considered if the permit Isforonc hunduddollan(5100)
or les>)
1 certify Not in the performance of Ne work for which this permit is issued.I shill not
employ any person in any manner so u to become subjuuo the Wmkcrs'C*mPCmmIbn
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.*fur tusking this Cenirmate of Exemption.you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
•J,Z forthwith comply with Such provision or this tomtit(hall be deemed revolted.
zi51 CONSTRUCTION LENDING AGENCY
F work
which run Wtthcrt les commotion lending agency for due per(urmsnrx of
W the work for which thts permit is isstxd(Sec.3091,Ci,C.)
II, Q Undoes Namc
z Lender's Add.,
V Q 1 anify that I have road Nis application and sate dust the Show information is
W U buildin I agree c comply with all city use county nNi vox of and tux lens relating e
OU above-mentioned!
construction,andforebyamhonurpose& atives of this to enter upon due
W Shovices,judneal ns.crty for expnion purwhich m4
fY (We)ague m saw,indemnify and keep harmless Dae City of Cupertino agaiut
Z in co ettieale of the gratsing eapenwmit. may in my way teem*egainu sane City
t.)',Z AcPLICANee of thegrantingof this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI ALL ALL NON-POINT Issued by: Date
910GULATI N . `'r
5.25(04 Re-roofs
r{nuurc aMpplicaHAZARDOr ATERIALS DIS CLOSURE Date Type of Roof
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
de.Section 35533(0] All roofs shall be inspected prior to any roofing material being installed.
❑YG R40
Will the applicant or future but
racusam sex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir ha'rardnu air comamimmus ss deOncd by the Bay Area Air Quality Management all new materials for inspection.
Disuia7
0Y WU
In aw uad Ne hvardnus mucriats requiuments underChapxr6.95 of due Gliforc
nfa Health a SafetyCocie,Sectiou]5A)5,35533 and 25534.I undersand duuifdue building
docs not curren0xm,
y ham a nanl do,it is my uspihility in notify six atopens of the y Saw, TT-e-2b•..-- J
rcyuiremcnts which must metprhowissuanecnncenina,te ora<*pan*y. Signature of Applica Date
S:Z� O
Owner or emhori'rtd agcm g
All roof coverings to be Class "B" or better
Dote