04020060 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ONTRACT R
BUILDING ADDRESS: PERMIT NG04020060
R'S NAME: PERMIT ISSUE DATE
MOGHTADER
NE: SANITARYNO. CONTROL NO.
ARCHITECT(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
06 LICENSED CONTRACTOR'S DECLARATION
1 Wmby affirm that I am limned under previsions of Chapter 9(commencing Job Description
with S.Mm7Of1B)afDivi0on3ofine Businua (cssions CoM,entl mylicense is
� � mhmmrcea re -70 r,, KITCHEN REMODEL
n n Z kcnm Cla( 200• Conte w O`er
ARCHITEC ash ATION CONTRACTOR: KENNETH �R CONST.
1 understand my plans shall M used u public mends r '
OyU
G LicensedProfessional
J91
OWNER-BUILDER DECLARATION hereby affirm mal I am exempt from the Commons License Law for the 2Un
0qO O following meson.(Smtiva 7(D 1.5,Business and Professions Code:Any city or county 'I
$ which requires a Permit to construct,altar,improve.demolish,or repair any structure pit IN. _
prior to its issuance,also acquires the applicant far such Permit to File a sigoedsu anent
p G the,he is licensed Pursuant to the povisiomor me Conuacmr'a License Law(Charter 9 Sq.Ft.Floor Area 'h Valuat4��500
yz❑ (commencing with Section7WO)of Division 3 of the Businessand Professions Code)or ••
y 3 ma
at he Is empl Merchant and me basis for the alleged exemption.Any violation of
ximoK0nan 7031d5 by any,applicadred nt iisppormlt subjects ma applicant to a civil Penalty of APN Number Occupancy Type
01,u owner of the property,in my employees with wages as lhehame compensation, 31640023 . 00
will do the workand the sWctu ,is nonimended ora@red reasons(See 7044.Business
and Professions Code:The Carotenes License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
awn amployoes.provided that such improwmenuase not imendrl unQerad Intends.If. .
however.me building or improvement is said within one year of completion,me owner.
builder will have tin burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contateting with licensed comments to
construct the pmjca(Sec.7044.Business and Professions Code:)The Contractor's LF
cerue law does not apply in an owner of property who builds or improves thereon.and.
who convects for such pm)eeu with a contractor(s)licensed pursuant to the Consumer's
liicense raw.
IRrl am exempt under Sec. .B k P C fu this reason
137M�"l u Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlty of perjury ane of the following declarations:
have and will maintain aCenificam ofConsent to self-insum forWorker's Cont
n,u provided for by Secdon 3700 of me labor Cade,for the performance of the
far which this permit is issued.
have and will maintain WukcYs Compensation Insurance,as required by Section
of Ne labor Cade,for dm Performance of the work for which this permit is issed.
Wofkers Campem akm Imenanm ear.end Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF RXEMITION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not mcomplemd if the permit is foronc hundred dollars($1,M)
Inas.)
1 certify that in repp performan a of the work for which this Permit is issued,I shall at
employ any Note rta0 manna,m as to�,ecamesub'actn the Worker'Compensation
Laws o(Cal' y am. "
Appli am A✓` z oa.!
NOT PPLICAf.after making this Ccmficalb of Exemplian,you should
boa bject to me W rkcrs Compensation provisions of the Labor Code,you must
,J O toMwi comply with such previsions or this permit shall be dimmed revoked.
z % CONSTRUCTION LENDING AGENCY
[—s I hereby affirm that them is a construction lending agency for the Performance of
a„>„, the work for which this Permit is issued(Sec.3097,Civ.C.)
;L.
Q Lenders Name
r7 z Lender's Address
U Q I certify that I have mad this application and sum that the shove information is
correct.l agree to comply with all city and county maintenances and ante laws relating to
0 building convection,and hereby Whorim mprmenutivea of this city to enter upon the
W above-mentioned property for Inspection purposes.
gy (We)agree to save,indemnify and keep harmlass the City of Cupertino against
N rq liabilities,judgments.costs and expenses which may In any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATIONS.
Re-roofs
rc ApplicanUC Dem
H DOUS MATERIALS DISCLOSURE Type of Roof
Will Um epplic tar future building mcupannamrc or handle hrmNous material
as derined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
rade Section 25532(a)7 -6No All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or runts building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 0No
I have mad the lustrous materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code Secuans 25505,75533 and 25534.1 understood]dra lithe building
does not currently have a tenant,that it is my nesponsihilitynoel' the acupanl of me
mquimm Gwhich must .01pdortoionumentsCeniBcamo sane. Signature of Applicant Date
z �
woe orad .c agent Date All roof coverings to be Class"B”or better