06020152BUILDING DIVISION 1'L+,K114r1'-ktlflitc�a���I�•
BUILDING ADDRESS: KORNATI PROPERTIES PERMIT NO. 0 6 020152
7516 ORANGE BLOSSOM D
OWNER'S NAME: PEST ISSUE DATE
19084 TILSON AVE 02 24 2006
PHONE: SANITARY NO. CONTROL NO.
(408) 996-2817
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i O p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
t vZ cu with Section 70(10) of Division 3 of the Business and Professions Code, and my license is
s = H in full forand effect.
? a License Class Lie. #
Date Contractor
ARCHITECTS DECLARATION
—t 1 understand my plans shall he used as public records
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4 U. ,t"„ Licensed Professional
y OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason. (Section 7031.5, Business and Professions Code: Any city or county
V� which requires a permit to construct. alter, improve; demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
2 0 that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
h (commencing with Section 7000) of Division 3 of the Business and Professions Cod") or
y that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (M).
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❑ I, as owner of the properly, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended oroffered for sale (Sec.7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves theeon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale- If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
<L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U-
cense Law does not apply to an owner of property,who builds or improves thereon, and.
who con",p4 for such projects with a contractor(s) licensed pursuant to the Contractors
License
❑ lam exe pt under , B & P C for Ihi reason
Owner.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for WorkersCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Workers Compensation Insurance Carrier and Policy number are.
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not be completed if the permit is forone hundred dollars ($10D)
or Iola)
1 cenify that i the performance of the work for whit¢ this permit is issued, 1 shall not
employ any pe n in any map cr so as to becomes eCt t ISe Workers' Compensation
Laws of Calif ice. Dat J-
Appllcant f
NOTICE of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY,
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We.) agree to save, indemnify and keep harmless the City of Cupertino against
Ilabilides, Judgments, costs and expenses which may in any way accrue against said City
in conseq ce of the granting of this permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR U TIO
Signature of Appliant/Contraclor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as deri nod by the Gupenino Municipal Code. Chapter 9.12, and the Health and Safety
Code., Section 25532(a)T
❑ Yes 16 No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes )NNo
Job Description
REMODEL BATHS (2)/INSULCATION, GAS LINE
SHEETROCK, SWER, REPIPE, ELECT. OUTLETS,
CHG DOORS, HEATER AIR DUCT
Sq. Ft. Floor Area j Valuation
$42000
Number
Required Inspections
Issued by:
Re -roofs (,
Type of Roof
Occupancy
Date
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.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does no eta mI haTwo!Ihalilismy resonibility to notify the occupant of the
require ton whicho issuanceof a Certificate of Occupan
11 7—A,-t 6
Ownd dr rdaulhorized agent I Date
Signature of Applicant
Date
All roof coverings to be Class "B" or better