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BUILDING DIVISION
?1928 OAK
OWNER'S NAME:
a. EDWARD
1 artery affirm that l am licensed under provisions of Chapter 9 (commencing
wish Section T"Onf Division Jof the Buvincss and fcssionxC Jc, and myliccnsc is
in full for and'y l/Qa17C
License C1� t.f ' • � Lic. p
Dale Contractor
A CPS DECLARAT N
I unarsRha m all W =it ax oublic'Or nrds
Lic'co SIQI fofax—O. l
OWNER BUILDER DECLARATION
1 herchy affirm that l am exempt from the Contractor's License Law far the
following masob(Section II31S. Business and Profession Cade: Any city no county
which requires a permit to construct. eller. improve, demolish, or repair any structure
poor to its issuance, also myuims the applicant for such permit to file a signed. statement
that he is licensed pursuant o the provisions of the Contractor's License Uvv(Chapter 9
(commencing with Section 7000) of Division 3 orbit, Business and Profusions Code) or
Nat he is exempt Ihemfrom and the boss for the alleged exemption. Any violation of
Section 1031.5 by any applicant for a permit subjece, the applicant to a civil penalty of
not ..or Nan five hundred dollars (SSW).
El I, M owner of the PoOreny. Or my employees with wages as their sole cam pensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7064, Business
and Professions Code: The Contractors License law docs not apply to an owner of
prapeny who builds or improves thereon, and who does such work himself or through his
own employees, provided thm such imprtontra tsare not intended or offered for sale. If.
however. the building or improvement is sold within and year of completion. Ne owner -
builder will have the burden of proving that he did not Wild or in prove for purpoes, of
sale.).
❑ 1. as owner of the properly, am exclusively comraeting with licensed contractors to
construct the pmject (Sec. 1044, Business and Professions Code:) Tho Contractor's Lt.
cane Law does not apply to an owner of progeny who Wilds or improves Merton, and
who contracts for such projects with a contraaor(s) licensed pursuant to the Contractor's
License law.
1 am exempt under Sec. , B 6 P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate or Conaenuo self-inaum for Worker's Compere
tenon, as provided far by Section 37N) (if the Labor Cotle, for the gerfomtanee of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compenxntion Insurance, as myuired by Section
3100 of the Libor Code. for the performance of the work for which this germ it is issued,
My Workers Compensation Inrunntt carrier and Policy nu.Mr art:
(This section need not W completed if the permit is for one hundred dollars IS IBB)
in less.)
1 unify that in the verrotm ince of the work for which this permit is issued. I shall net
employ any cnon in any manner set so m become subject to the Workeri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Ccnifcale, of Eacmption, you should
Weome subject to the Worker'a Compensation provisions of the labor Code, you mon
forthwith comply with such provisions or this permit shall be deemed mvokrd.
CONSTRUCTION LENDING AGENCY
1 hereby off roe that there is a construction lending agency for the infurmance of
the work for which this permit is issued (Sec. YN7. Civ. C.)
Lender's Name
Under'a Address
PERMIT NF)410 0 10 1
PERMIT L%UE DATE
10/14/20
SANITARY NO.
BUILDING PEI
BLDG ELECT
Job Description
KITCHEN REMODEL
CONTRACTOR: KINNEY CONSTRUCTION INC
32618048.00
Required Inspections
1 ecnify that I have read this application and stale Nat the aWvc im` not 0; is
torten. 1 agree to comply with all city and county ordinances and sire laws relating m
building construction, and hereby authorise mprescmadves of Nis city to enter upon IW
above-mcminned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and ex recent which may in any way accrue against said City
in conseyucncc ofth of this permit.
APPLICANT U ERSTAN AND WILL COMPLY WITH AL` NON-POINTLISSUed
SOURCE REGULA 1
HAZARDOUS MATERIAbS DISCLOSURE
Will the applicant or future building occupant store or handle hararduus mateoal
as defmcd by the Cupertino Municipal Code. Chapter 9,12. and the Flcaltb and Safety
Code, Section 25532tap
❑ Yes
Will the applicant or future building occupant use equipment or devices which
nil lentil air conmminame as defined by the Bay Arca Air Quality Management
Oinrict?
❑Yes1
I have mad the havardous materials requirements under Chapter 6.95 of dm Califon.
on Health k Safety Code, Sccduns 25AI5,25533 and 25534, 1 understand that dust Wilding
dies not currently hareat it is my rcerombility w nosily the oecupanl of the
rcyuimmcnts which muss have=
orlolssunccnfa CcnificatpofObcu,dcq I
Re -roofs
Type of Roof
Dale
w
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better