03080117 CITY OE CUPERTINO ��' sy- T"
BUILDING DIVISION PERMIT CONT==RACTOR�INF9RMATIOO N
" No ADDRESS: UTLEY NELSON V AND BARBARA 'K"""03080117
DR
-R'S NAME: PERMLT I SUE DATE
Ng; SANITARY NO. CONTROL NO,
ARCHITECI'/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
8,Z, LICENSED CONTRACTOR'S DECLARATION
u I hereby affirm thm 1 on licensed under provision of Chapmr Y(commencing Job Description
!�E with Scaion]IkRp of Divislon3orthc➢using.vantl Prufcaslam Code.andmyliccnsc is FINALE®
ifull n
j Z forceand arm"'
License Class KITCHEN REMODEL
Dam Contractor
DELL Ukg'',�
�EE ARCHITECrS DECLARATION CL 1 7 2003
1 k 1 understand my plans shall he used as public records ,
)yU
°O LiccnSCU Prolcxsianal o w .
OWNER-BUILDER DECLARATION
BUILDING
a X I hereby affirm that I am exempt from the Contractor's License Law for the �I
O O following mason.(Semon 7031.5,Business and Pm(caainns Code:Any city or county
e 8� which requires a Permit to construct,alum,improve,demolish,or repair any structure
a prier In its issuance.also requires the applicant for much Permit to Olc a signed statement
m< that he is licensed pursuant to the pmvisionnf@eCnmmcmr'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuatwn
21-Q (commencing with Section 7000)or Division Sof the Business and Prorwions Code)or
that he is exempt doorman and the basis for the alleged exemption.Any violation of 32635029 . 00
Section]031.5 by any applicant for a permit subjects the applicant o a civil penalty Of APN Number Occupancy Type
not more than five hundred dollars(S50)L
❑1,w owner of the Company,or my employees with wages as their able compensation,
will do the work,and the structure is not intended or offered for ale sec.7W.Business 101 — =DAIej(P d Inspections
and Professions Cade:The Contractor's Licenx Law does not apply to an owner of 10 2 - ,PIERS
proper who builds or improves thereon,end who doessuch work himself or through his
owncmployces,provided that such improvemenuare notintended oroffered forsale.If, 103 — UFER
however.me building or improvement is sold within one you oreompletion,the owner -
builder will have the burden of moving that he did not wild or Improve for purpose of 104 — REBAR
0"le')
as tweet of thr
e prope ,am exclusively convecting with licensed Contractors to 105 - ANCHOR BOLTS
a
0..In)
the project IS
jeec.]baa,Business and Inclusion,Code:)Toe ConvactorY u- 106 — SEWER & WATER
cense Law does not apply to an owner of property who builds or improves themun.and 202 - UNDERFLOOR PLUMBING
who contracts far such projects with a conanctons)licensed pursuant to the Contractor's
Licenaal-aw. 203 - UNDERFLOOR MECHANICAL
of mon Can pr ,Se B&PCfar this ssop
I u ' Data Z O 204 - UNDERFLOOR FRAME
'R'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby elfnd under pcnelty of perjury one nfehe following declarations: 301 — ROUGH PLUMBING
I have and will malnaln a Certificate of Consent to ser-lasum for Worker's Curdled- 302 — TUB & OR SHOWER
cation,as provided for by Section POO of the Labor Code,for me performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Inunnec,ss required by Section 304 - ROUGH ELECTRICAL
POO of the Labor Code.for me performance Cliffe wad far which this permit is Issued. - 305 — FRAME
My Worker's Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Currier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(TTuseetion need not becosoncied if the permit is for one hundred dollars(SIM) 309 - EXTERIOR LATH
I,Certify 310 - INTERIOR LATH
employ
mm in cob performance of the work for which this permit is issued,1 shall not
Law oanypcnonmanymannerseasmbewmesabjccuntheworkcnComPcmatian 311 — SCRATCH COAT
Laws of California.Dere 313 - ROOF NAIL
Appfieant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
hecame subject to the Worker's Compensation previsions of Out Labor Craft,you must
.JZ forthwith Comply with such provisions arthis permitshall he Coached mvokcd. 502 — FINAL PLUMBING ENERGY
z8 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(:. 0 IherebyalRrmthatthemisaconawctionlendingagencyl'nrtheperformanceof 504 - FINAL BUILDING ENERGY
C(i > he work for which this permit is Wood(Sec.709],Co.C.)
ip ander'aNme 505 - FINAL ELECTRICAL
z Lon aer'Add., 506 - GAS TEST
U O 1 certify mat I have read this application and save that the shove information is 507 - FINAL PLUMBING
torten.I agree to comply with all city and county ordinances and state laws relating to
�U building construction,and hereby authbriae represenutivct of mis city to curer upon the FIN MECHAN CAL
} U above-mentioned prefer for inpection purposes.
F+
(we)egrte m arc,indemnify and trcp harmless the City of Cupertino against 0 9 FIN
h inConseqjudgments,cosuangofmisseswhichmeyinanywyacrnrcagamstwidCity 5 A NG
UvZ in Consequence judg ethe grunting u(thispermit.
'—' APPLICANT R AND AND WILL COMPLY WITH ALL NON-POINf Issued by:5 WORKS Date - Z 3 oE
50
71 Re-roofs 07
g a of 1G° id
HAZARDOUS_ MATERIALS DISCLOSURE D Type of Roof
Will the applicant or future wilding occupant stare or handle hatmous material
def bell bythe Cupertino Municipal Code.Chapmr 9.12,and the Health and Safety
Section 253P(ap /
❑Yea All roofs shall be inspected prior to any roofing material being installed,
Will the applicant or forum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air cobtaminanu as tkGned by be Day Area Air Quality Management all new materials for inspection.
Ontario,? ��/
❑Yes Lunt
1 have read the harandousmamrials mquiremenu under .Chapmr 6.95 of me Califon
ilia HCulth&SofcayC Sccuunx 25XI5,335JJond 355Ja.l undersand thatifthc building
docs�Wa<rt`i{pnffj of pant, at it it my res nsihiloy m mm y me occupsm of the
rt mooned must in Hotn, u racertifmamofsea r. Signature of Applicant Date -
crura thoriveJegem All roof coverings to be Class "B" or better