04110173 CITY OF CUPERTINO 7a 7777775 S •7 • �"� �°"' ��
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION`
BUILDING ADDRESS: PERMIT N0.
KAISER CONSTRUCTION 04110173
884 LGRER AVG -NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY OL NO. -
ARCHITECTYENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION Job Description
vpar 1 hereby.Ram that I am licensed under pmvWons of Chapter 9(commencing
zw with Section 7000)of Division 3 orthe Business and Pmfcssinns ode,and my license is
in full force and circes.
�'q? ueenme Clean Lie.9 CONVERT BACK TO CARPORT
Zia Das Ccnarwtor i CONTRACTOR: KAISER CONSTRUCTION
to HITE,,DECLIRA ID
'yS e I undcraunJ m plans mball W used we public records
�yU
3 uO y Licensed Professional
3 OWNER-BUILDER DECLARATION .
I hereby atGrm that I em exempt from dte Contractor's License Law for the
m0 fallowing mason.(Section 7x131.5,Business and Professions Cam:Any city or county
which rcquirm a permit m construct,aim,,Wprow,&..fish.to repair any sweture
++mow prior to its issuance,also mquims the applicant for such pumiuo file.signcd statement
that he is licensed pronouns to the pmvisiom of the Contractor's lxcnse Law(Chapter 9 Sq.Ft. Floor Area Valu aetr-rn
¢�$ (commencing with Scction7000)of Division 3 of the Busircss and Profnsirns Code)or �BOOQ
F_ Nat he is comp,theanom and Ne beau for One alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more Nan Fmve hundred dollars
0 I,as owner of the pmpeny,to my employees with wages as their sole compensation. I-'-s n 3 7,515 0.15.. 0 0
will do the wont.and time swcture is not intended or offered for safe(See7(t44.BmuinevI r
and Professic s code:The Cmi.es License Law dues Wt apply 0 an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
Own cmployees,pmvidcd Nm such improvements are not intended or offered for sale.If. �. /^
however.We Wilding or improvements er- l oft is old within one yew of completion,the ownl
builder will have the burdan of pmving that he did not Wild of improve far purpose of 2�G5
salo).
0 I.as owner of the pmperry,am exclusively contracting with licensed contractors to
comunettheprojeci($eeJtWa,Business aria Professions Coae:)The Conuacmr's Li t) f'
cense law does not applms y to eco owner of property who Wilds or impmws dmcmon.and ( .. n
who comfor such pmjecu with a consumgs)licensed pursmnnothe Comm�ors �� w
License Law.
❑1 am exempt under Sec. .B&P C for this reason r
u Date
WORKER'S COMPENSATION DECLARATIONRim
1 hereby am under penalty of perjury one of the following declarations:
Dihsw and will maintain aCcnifcam of Consentla self inauro for WortermCompcm
dationea pmvidcd for by Session 3700 of the Labor Code,for r the petimmana of the
wont for whim this perms is issued.
0 1 have and will maintain Workers Compensation Imuran.,as required by Section
"I or the labor Code,for the pmform umc of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Policy No.: -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rlbu secure recd not W completed if the permit u foronehundmA dallws(SHad
or less.)
1 eerufy that in use performu cc of the work for which this permit is issued.I ahall nut
employ any peron in any inne Jutta MSune subject to the WeeeotrKCompensauon '
LawsApplica California.Dam�,__)_-kms A
NOTICE
F�'tr mmol
NOTICETOct APPLICANT:ILS rrakang uCcnonsofcate the Labor Code,
you
become Object to ante Workeh pens tion previsions of the Lahnr code,you must
.,z foMwith comply wldm such provisions or this permit ShallW decreed avoked.
zO CONSTRUCTION LENDING AGENCY
IM1crcby aRrm that there iso consuucsirn lendingagcncy for the perfornmom of
rL 7 the wont for which his permit is issued(SIL.3097,Civ.C.)
{5d 0 Under's Name
f1 Lender's Add. '
V p 1 unify that I haw mad this application and suite that the amove infrmation is
comet.1 agree to comply with all city and county ordinances and state laws aiming to
O V building construction,and hereby audonte mpnesenuiuws of this city to enter upon the
G53 a now-menuonca property for inspection purposes.
We)agree to save,indemnify and keep humicu the City of Cupertino against
i,t liabilities,judgments,cams and.1.which may in any way Sec.agaimt Said City
V z APPLIC NTOUNDEof the RSTANDS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by:S4-t�(a Date
SOURCE REGULATIONS"
� Re-roofs
Signature of Ap,liu.rOC.nter Date
HAZAR OUS IvILVERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occuprutore or hwulc hainmdous material
as ac0ncd by the Ct,"I no Mum al Code,Cnapmr 9.12,and be Health and Safety
e. El Y.2ss32(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant nr fntore bnllding occupart use equip rmt or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
red,be,.dnm al,com uni anq u defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
0 Yes /'�,n/''`q
I have mad the WmaNnus materials requirements under Cha ucrti.95 of the Califor-
nisHealth&Sarety Code,Sections 25505.25533 and 25534.1 undersand thmifthe Wilding
does not currently hoc a anent that it IS my nmpumihility m noufY the Occuprt Of the
mquimmens mu metpriUrW,utionROraCenlfcatcorocup cy. Signature of Applicant Date
owners orixeaape $ All roof coverings to be Class "B"or better