04020069 CITY OF CUPERTINO fir, wwa•��'tt` Y �ry .u+ ` f
BUILDING DIVISION PERNIIT �.„,oWRACT�ORj,NF4RMA,T O,N ,
BUILDING ADDRESS: PBRMIT N0 04020069 4020069
R'S NAME: PERMIT LSSUB DATE
PAUL & JOANNE
PHONE: SANITARY N0. CONTROL NO.
ARCHITEC(ENGINEER: ., {� BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O
+lop LICENSED CONTsedordR'SDECLARATION �( `'.1766 Description I
1 Wroby affirm wall am licensed under provisions of Chapter 9(commencingEcsseis I _ / 1
x
with Section7daffecDlWdon7ofbe 0udrcsasnd Pro(cssiou Code,and mylicense is ✓ its'
in farce and offal.
�gLicense Class tic.. KITCHEN REMODEL.
Dem Commuter 11Li
ARCH I'IECI'S DECLARATION IJP IJ L
e'
y I understand my plans shall bo used u public rccmds �
3� Licensed proportional '
OWNER-BUILDER from
DECLARATION
1 berchy.Sect that 11. exempt from the Contractor'sarsCc :My c Law far Ibo
o O following Raton.Dation 71111.5,Business and rm,de ions Coda:Any oily or county
9 which mqulRa•merman 70[nmusu0.applicant
Wpove,doermitt or Rpbr any statement rnnnn
prim b ill lensed p rIW RGnIIG the porvis liam for suchCon Permit tofile a signed.(Chains,
< than he(comms llanseopursuant70the ofDivians 3ortheRusebfsndProflJw(lCade)9 Sq.Ft.Floor Area Valuation
$O that 1. sing with Sectionefrum and of basisofar w the Bminesa and on.my ns Cade)of
But io r campy rMacfrom and we bur far IW alleged esempnan.Any violation of
Section 7051.5 five
any red doll far a permit subjects we applicant to a civil penally of 3 5l!JT4T "cr0 0 Occupancy Type
rot teas than five hundred dolma(SSW).
❑I,u ownes of tm propmy,a my wployea with wga u dmkmk compeesadon.
will dodo work and westocturn r not intended eroffted fmsele(See.7041,Business
and Professions Cade:The Gmrsebfs License law does rot apply to an owner or Required Inspections
proper ywho Wilda orlmproves thereon.and whodoessuch work himselforlhrough his
own employees.provided that such imp onve.anhis art not Intended or offered(or sale.IL
however.be building or improvement is mid within ane you of completion,wr owner.
build"will haw the Wrden of moving thst be did rot Wild or improve fm purpose of
sale.).
❑1,as owner of the property,am exclusively contracting wit licensed contractees to ,
common Ne projest(Sec.ION,Business and Prof"mus Code:)The Coetranar's U.
came law does not apply to an owner of property who Wilds or Improv thenen,and
who mmracu for such pokeR with.choro wro)licensed Formant at be Canuactor'a
License Law.
❑larm ex9n//pt//nda Sea B&PP^C fa r onDaw�P
rV( RKER COMPENSA77ON D ON
1 homby of can under penalty of perjury am f allowing decluatimur
❑fha0andwlllmainWnaCerdrinleaf Com)ntsomlf-Insumfer Warkce Compen-
atiom,upro fpe Secda57000(the Colyte Code,for ote performance of the
work for whichh this permit Is isamd.
❑1 have and will maintain Worker's Compensation Inman,as required by Section
3740 of tiro Labor Cade,for wo performance of the work for which thio Permit is Issued.
My Worker's Compensation Inmate)carrier and Policy number w:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
nTrmmion need rot be completed If ted Parnell Is Intend hundred dollars($1 00)
or leu)
1 artily bet in the performance of we work for which this permlt is issued.)shall not
employ any person in any manner an as In become object to the Workers'Compensatron
Laws of California.Data
Applicant
NOTICE TO APPLICANT.IL aflat making this Cenlfia a of Exemption,you should
become subject to be Worker's Compensation provisions of the labor Cad),you mw1
.JO forthwith comply with such pfmWnns or this permit Nall W(lamed Invoked.
Z Fr
CONSTRUCTION LENDING AGENCY
teI herchy aff1
Oat were is construction lending agency lot the performance of
gyv r t On work for which this permit is issued(Sec.3WL Civ.C.)
W�Q Lender's Name
.7 z Lemwes Address
U O i certify that I have Rad this application and sum that on above information is '
ly corset I agree In comply with all city and county ordinances and sum laws relaxing to
O U Wilding canstraction.and hereby wooden representatives of this city to enter upon th
W ehovc(We)aned property for Impaction purposes
(W .
IA o)ina 70 ave,indemnify and keep may
in m we City o(Cupen t id City
IA inconseque consequence
of th.ewuang of this permit. may in my way roma agtlnst said City
U7 in corlsCANTcof D)gnmiNDSAspermit.
F7 APPL CANT UNDER ANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
SOU A
Re-roofs
atuo of v ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant m Muni WildingChaore or lunda
k hama
rdous terial
defined by the Cupertino Municipal Cade,c.Chapter 9.12,and the Health and Safety
e.Seeder xss3xla)7 Ya ygN���///o All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant or future building=upon,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
)mil heurdnw air canlaminann u defined by the Bay Area Air Qulity Management all new materials for inspection.
Dimict7
❑Yes u r
Ihavemad the h rmloto materials requiremenu under Chapter 6.95 of the Califor.
nr Halbg:Sa(otyCodc.Sadwx5505,x5333aW x5534.1 undersand buifbe Wilding
does not currently It ant brcpmhm noy OOut ofbe
m)I my . m
nequt
Signature of Applicant Date
Ow tar jA All roof coverings to be Class"B"or better