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CI'T'Y OF CUPERTINO
CONTRACTOR INFORMATION
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERNIIT NO 410 0 11 9
1691 LINDY LN
OWNER'S .FAME:
PERMIT ISSUE DATE
TOM & BARBRA EVERMAN
10/18/2004
)Ni::
SANITARY NO. CONTROL NO.
ARCI IITECfIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR DECLARATION.
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
derp
P
wish Section ]J)1NI) of Division J of the Buxiness and . ofcssinns Code, and my li¢nsc is
nfull I; an (feet
KITCHEN REMODEL
"Graz` r Lie. "
Dale Contmnor
CONTRACTOR: JCT CONSTRUCTION
ARCHITECTS DE ON
onand my plans Shall W seed as records
Licensed Profesimmil
OWNER -BUILDER DECLARATION
I hereby alfirm that) amxempt from the Contractor's License Law Inr the
following reason. Scrum 7831.5 cBusiness and professions Code: Any city or county
which requires a Payment to construct, alter, impmvc, demolish. or repair any structure
prior to its i xione,, also requires the applicant for such Permit to Glc a signed statement
that he is licensed pursuant Le the pmvisionsofthe Cumncoy'.c Licensee law eehaptce 9
Sq. FL Floor Area
Val6000
(commencing with Section 7003) of Division) of the Business and Professions Code)or
that he is exempt therefrom and du buis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occu ane I' e
P Y YP
not more than five hundred dollars ($50Y.
35222019.00
❑ I. as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. ]Baa, Business
Required Inspections
and Professions Code: The Contractor's License law does not apply to an owner of
property who builds or improves thereon, and who dyes such work himself throughr his
cd or rule
Own employees, provided for rule. If,
ear
pr vemimprovementsarcnot mofferN
of
huilder, Nebuilding within one year or completion. One owner
uimprovementissad
builder will have the burden of proving mal M did not Wild or improve for purpose of
/
0 1. 1. as owns of the property, exclusively contracting licensedrisContractor's
ca. Lct aw. B Cod i
owner of property who selids or improves hereon. end
ees Out(See .toWye, Business androp Professions Code:)Thoves hereon. std
law does oat apply m
who
who contracts for such projects with a eomranor(s)licenud pursuant to the Contractor's
u
Licca Law.
/^
❑lam exempt undo Sec, .B&PC for this rcuon
v\
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-iacre for Worker'sCompcn-
IDtion, u provided for by Section l]W of me Labor Gadc, for the pctformancc of the
work for which this ry:ranit is issued.
❑ 1 have and will maintain Worker Compensation Insurance, a requited by Section
J]G] of the Labor Code. for the perfmmanee of me wink (a, wl�ww�/n s permit is issued.
M llit Compensation Insurance carrier and Policy numocrate:r
Ca � 'I'LL'rcit')Policy Ne.: ✓ —
I
C' TIFICATE OF OF EXEMPT10N FROM RK RS'
1
COMPENSA]'ION INSURANCE
(This section need nut hecumple¢d it t W permit is for.. hundred dollars (SPINO
nr I's'.)
1 econv that in the perfomunee of the work for which this permit is issued, 1 shat not
employ any person in any manner sit as in Wcomc subject to the Workers' Compensation
Laws Of California. Date
Applicant
NOTICE TO APPLICANT: If. attar making this CeniOcete of Exemption, you should
became subject m the Worker's Compensation provisions of the Lahr Cmlc. you most
forthwith campy with such provisions or this permit shall be deemed reveled.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the Performance of
he work (or which this permit is issued (Sec. 309t, Civ. C.)
Landers Name
Lender's Address
1 certify But I have read this application and state, thu me above informmiun is
torten. 1 agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorise rcpareutmivas of this city to enter upno me
abovementioned properly for inspection purposes.
(We,) agree by save, indemnify and keep harmless the City Of Cupertino against
liabilities, judgments. costs and expenses which may in any way same agamsi.seid City
in con ocncc of deals. tog ufthis pc it.
APPLI NT UNDERST N ILL MPCY WITH ALL NON.PPINT
Issued by: D ate
R L�REGUL I i�nJ(1/r/s
G
Re -roofs
o A It n pnlreclor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Willme pplicantor future building occupant store or handle lm>ardios material
az defined by the Cupeninn Municipal Code, Chapter 9.11, and the Health and Safety
Cale. Semon 15512(x)? �,,ss///
Ayes �gjNn ���
All roofs shall be inspected prior to an roofing material being Installed.
P P Y g b
I
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
g
it haeafdous air contaminants az defined by the Bay Arca Air Quality Management
all new materials for inspection.
JI
imrlet?
Dyes (/yxw'
-
I have read the humedi mamriuls requirements under Chapler6.95 of me Califer
Iia tical .' Safciycotle, Secdea 255(15.155) and'S5Ja. I understand thin if Or Wilding
docs no 'prtcntly haw a tenant tint it is responsibility w notify the Occupant of the
rcq re, Ica which mu m prior lass ante of u eniGcate of occupancy .
-
Signature of Applicant Date
olid nc
All roof coverings to be Class "B" or better
nee or author of agent Dam