04030144 r—OTTY OF CUPERTINO
BUILDING DIVISION PERMIT �,CONTRACTOXTNFO
BUILDING ADDRESS: KIMBERLY PAGE """'04030144
4�;c; nRANrR AIT
M'S NAME: PERMIT ISSUE DAM
KIMBERLY PAGE,
0 0,
NE: SANITARY NO. QCONTROL NO.
A ARC
RCHOIN71ENGINEER: BUILDING PERMIT INFO
BLDGits PLUMB MECH
40 LICENSED CONTRACTOR'S DECLARATION
I handery affirm Mat I am licensed ad.provisions of Chapter 9(commencing Job Descriptio
who Seefice.7") 3.f Me Bud...and Preload..Code.and in,license I.
FINALE
UWD
in full force and effect ADD- 304 SQ. FT. /UPGRADE
License Class-Lt..11
Z Dam-Cminuccoul
ARCHITEcrS DECLARATION NOV ?_ 2004
I understand my plans shall he used as public records
�twt; Licensed Professional
�0 OWNER-BUILDER DECLARATION
E:m following motion.(Section 7031.5,Business and Preposions Code;My city or county
1. 1 hereby afflon[hat I ma tomerpt from the Contractor's License Law for the
BUILDIN
2 which.,.ims.Permit 11,castanet.21101,improve.demolish,or pan any structure
priormiti issuance,also requirm the applicant forstich Pimento File asigned statement WIDE
fleathe is liecrowd parimetunt ft provisions of the Contractor's Lomas Law(Chaideri? Sq.Ft. Floor Area Valuation
(cat Scoduel")anivision3ofths,fluchroustand vi Coda)
Net he is exampt dominate and ft brusit;for da,alleged exemption.Any viDiatfon of
Scene.7031.5 by any ppikeent for a Permit subjecia the applicant I.a civil Penalty of 3 9LPN4N1u-hber0 0 Occupancy Type
net marc there five hundred doll.(MOO).
0 1,as owner of Me property,or my employees with wages as their sale compendium,
will do Me work.and destructors is not intended or offered for sale(Sec.7044.Business
and Pftems Cod.:The Commucter's License Less does not apply to A.owner of Required Inspections
oolicie
property who builds orimproves thereon,and who does such wad himself orthrough his
own employees,provided thatiorch imprawamemn am not intended oroffered formic.If,
however,Me building or improvement fiBsold within one year ofoomplefion.Me owner
builder will have the burden of proving Met he did nor build or improve for purpose of
E]1,as owner of de property,am exclusively contracting with licensed contractors to
coni[he project(Sec.704th,Business and Professions Codi The Contractor's Li.
come Law does not apply to an owner of property who builds or improver doescort and.
who contracts for each procen;with a conermhou(s)licensed pursuant to the Comactor's
License Law.
❑I.aim7B&P C far this manure
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/ 7 r7am
WORKER'SCOMPENSATION[17�MATION
t./I thereby afford under penalty of perjury c Me following doolandion
I have and will maintain.Certificate of C.ems.t to elf-insula for Wo leer's Compen-
action,as provided for by Section 37M of Me Letter Coda,for Me performance of ft
work for which this permit is leaned.
'a"mi
wera0 1 have no will maintain Worlaer's Compensation becomes,as required by Section
nal
IC331'W of the Leon Com,for Me perfunmance,of Me work for which this permit is Issued.
MY"
My Worker's Compensation Insurance carrier and Policy number am:
Cartier._Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section read notloccomplined Home Permit Is future hundred ififflare($1010
edeas.)
learfifY Nat in me performance ounce work for which this facurall is isomed.I shall not
employ any peomnin� norastobac bjmt t. deens'Comperesdon
LawColiforms. �r
NOnCiOmuPPL, T.aftlerfirldflilip-tus Certificate of Exemption,you should
bttomeso
ce
so tuatic, arkees Compensation provisions of thic Labor Come,you must
0
O amply with such provisions or this Permit shall be deemed commit
z 0
CONSTRUCTION LENDING AGENCY
14 Thereby snort this,More is a construction lending agency for Me performance of
ai> the work for which ibis permit Is issued(Som,307.Civ.C.)
aELender's Nine.
rtez04 lender's Address
U 0I rentify that I have read this application and smue that the show information is
Fcorrect.I agree to Comply with all city and county ordinances and show lam holding be
U building construction,and hereby audience representatives of this city to enter upon Me
;Mr.v mmrd.mcd property for Inspection purposes.
(We)agree to save,indemnify and keep hisionlins the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way seem against mid City
in consequence of Me jounfing of this permit.
ti APPLICA4T UNDERSTANDS AND WIL ,COMPLY WITH ALL NON-POINT Issued by:
Date
SOUR E NS. yf
Re-roofs (�;7
Sig at
of m1ml/Cmdrache Dole 7
HAZARDOUS MATERIALS DISCLOSqR;E � Type of Roof
ell Mc sppiicanl or future building acupsnlamre or hona'.
clarmarimmiumucral
2d by the Cupertino Municipal Code,Chapter 9.12.and Me Health and Safe,
"ned
a,Sweden25532od?
0
E]ym rN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hooeMes air contaminants as coined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 yet KN.
I haw read the lumarchasionstanlid,outurenumus under C1mptc,6.95.fMaC.fifih,
= m&
nia Heal"Safety Code,Soctions 25505.25533 and 25534.1understand thrairthe building
not c ty ve a comen,Men!its my responsibility to rocky the occupant efulm
m�qui
quircurc met poor to issuance of a Comficas,0 cap Signature of Applicant Date
0er or authorrad agent m All roof coverings to be Class"B"or better
V7