04020059 CITY OF CUPERTINO € ' -�
BUILDING DIVISION PERMIT CONTRACTOR�INFURMATIQN ... -
BUILDING ADDRESS: PERMIT N00 4 02 0 05 9
64n MORRNrO TIP
IS NAME: PERMIT ISSUE DATE
MARYANN NA,JAET 02106 .2004
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT 0 PLUMB MECH
0 0 0
yOp LICENSED CONTRACTOR'S DECLARATION
F 1 Mreby affirm Nei I am littnted uMer pmvialont of Chapter Y(commencing Job Description
iW with Section 7MB of Division 3 of Ne Busrcu and profession Code.and my license is
n<to in full fn¢e and effect.
z� DamamGlaa cntaem REMODEL KITCHEN AND 'BATHROOM
cat ARCHITECTS DECLARATION
I undersand my plans¢hall W used u public records
to
;0� Licensed Professional
OWNER-BUILDER DECLARATION
<� 1 hereby alTrm Nat I am exempt from time Contractor's License Law for the
no following mason.(Section 703I.S.Business and Profusions Code:Any city or county
29 which oup ions a Permit to construct.alar.improve.demolb1b,car.,.it any sacrum
Fiy prior to is issuance,also requires the applicant for such Permit to file a signed statement
< Nat he is licensed purmagett.Me pmvisiovnfNc Cmustur's U..law(Chu'.9 Sq.FL Floor Area a tion
y�$ (commencing with Steven 7")of Division Sof the Business and Profusions Cede)or
Nat W is exempt Nemfrom and the basis for the alleged exemption.Any violation of
Session 7031.5 by arty applicant for a permit subjecn the applicant to a civil penalty of 3'�et0 0 Occupancy
not mom Nan five hundred dollars($500). P y Type
❑Lu even of da,pmpety,or is aimmce wlNwaguuNe'v sole eomPevadon,
will pr Ne work end Ne awnae i¢nor's Lia d onoRe do Nualc(Sec.loan,Business
and property
wh ore Code:The Convanlors Liam law docs not apply m rt rouge(of Required Inspections
own ertywho Wildsonimprovsuch reprmencom m,notMosscbwork foreteller ffedtfor ughWe his
own employees,provided that such impmrcmencs arc not eanded"offered for¢a mer,
Wiider.Ne Wildingorimprovement ismld withinore Sear or improv for theoseof
Wilder will Mrc the Wrdcn of proving that W did not Wild or improve for purpose of
salt.).
1,a owner or Ne properly,am esclusively contracting with licensed convectors to
I
nmm Ne pmjen(Sec.)046,Busincu cod Profestiam Codeq The Conuacmrs W
ewer Law does not apply to an owner of property,who Wilds or improve daemon,and
who contracts for such pmjeea with a commetor(s)licensed pursuant to Me,Gntreetora
License taw.
❑I un exempt under Sec. B&P C for this reason
'9Z.4L
ER
K 'S CO EN A �N DECLAR
\ hereby 911 under,crutyof duty one of the following decimations:
- I hate and will maintain a Cerufiva ofConsenuo self-inmm for WorYcri Compcm
sation,as;pmvided for by Section 3700 of Me labor Code.for Ne Performance of da,
wort for which this permit is issued.
1 have and will maintain Workers Compensation luau¢,u required by Section
3700.1'the labor Code.for the Performance of the wart forwhich Nis permit is issued.
My Worker's Compensation In¢vance carter and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Vila,Permit is forms,hundred d.11mu(SIM)
or Ica.)
I certify that in Ne performance of Ne..,it for which this pernit is issued.I shall not
employ any person in any manner an as to become subject toIW Worknir Compensation
Laws or California Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemptlmn,you should
become subject at the Worker's Compensation provisions of Ne LaWr Code,you must
., ,Z forthwith comply with such provisions or this permitahal W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F IhembY affirm that fere is a construction lending agency for Me performance of
p: Ne auric fur which this permit is issued(See 3097.Civ.C.)
dLenders Name
z Lender's Address
O C) 1 certify Nat I have mad Nis application and state that Me above information is
F' toren.I agree to comply with all city and county ordinances and tam laws relating in
O U Wilding emnswctimn.and hereby auNodm mPruenmives of this city to enter upon Me
4A alwvcmcmiuned pmpc costs
for inspection ees purpowhich
f~y (We)agree m cove,indemnify and kecP l umlus the City of Cupertino agaivt
z in
or M,crauind expensesmit. may in any way eccmc ageing mid City
fJ z in PLICANT mf UNDERSTANDS
leg of this permit.
APPLI�/LEANT UNDERSTANpS AND WILL COMPLY WITH ALL NON-(POINT Issued by: Date
SOURRe-roofs
S�a'lur,of DDLcanVContncmr Date
HAZARDODS h ATFRIAIS DISCLOSUR Type of Roof
Will the applicant or future Wilding arupapt store or handle Health
material
u defined by the Cupertino Munitlpal Code.Chapter 9.13,and the Hulf and Salcey
we,odes 2ss32(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yc¢ "�Nu
Will Ne.applicant or Nam building neem ant use a If a roof is installed without first obtainingan inspection,I agree to remove
Pat g P a Air Quality
err devices which P g
-7=-
it horardnus air contaminants u defined by Ne Bay Arca Air Quality Manascmcnt all new materials for inspection.
❑Yes u
veadtaeallb&Safety Cede,Seeders 25505,25533 and 25534.I undersand Naz if Me Wilding
not currently have a nem m.Nat it is my responsibility m notify Ne occupant of Ne
uireme u ich mug W met prior m issuance.( cmil"m ofOcupm v Signature of Applicant Date
' r, .rice s,nt is Da All roof coverings to be Class"B"or better