05040147 CITY OFCUPERTINO
BUILDING DIVISION PERMIT �dN�T12AC�,T�OY RhIN 'O'RMA'IIIO-,
BUILDING ADDRESS: PERMIT NO.
HOME PROS 05040147
OWNER'S NAME: PERMITISSUEDATB
h '-
ROBERT s DTPSICY NEMEC
�— SANITARY OL NO,
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONRAC11DWS DECLARATION Job Description
�1I barony affirm that I am licensed under provisions of Chapter 9(commencing
with Section? fDiWnonlof dte Buaiwuand ro(cumiooda.and mylkcnmis
in full force endd clrn
e
SEE Lima. Llc.g v KITCHEN REMODEL
Date
e RCHITEClTS DECLARATION ARATION /
y I undn
eunJ my platM
s tlbol used a public rmmJs
3 /3
i Licensed Pmfeuionel
�3s Oat I am exempt
from
m CLARATION
0 p I hereby amrm on 1 1. eumpl s an the Coto rs Co :A License Law for the v J�
p O whichfollowing mason.(Swim 11131.;Bu.iter.and ow,de ons COM:Any city or county
$ which rots Iso s permit re construct,the alter.Improm,demolish,or repair any mm�uro
poor taiul.,.wdpWstarequirhe lhn,is1.ant for such permit in 0leuigadstekmenl
gggg$F< thelhehliccnsedpSo it lnlhepmvielolo.3oft eB.alcloia dPoselaw(Chap¢r9 Sq.Ft. Floor Area
Valu seen
Q � (cat he 1.
So it
the
basis r3 of theeged cumlon,An vi Cco)tion or
Of
dv 33 Sec io 7 exempt tang applicant
li and the bub for be alleged Gumption.Any l penalty
of
net on thin many reddeltforapmlt.ubjecutheappllesmtaacivilpenallyof 3,T �I�lytperpp Occupancy Type
not mom Nan Bve hundred dolhn(f500).
❑I,u owner of the property,Or my employees with wages u 0telr sole compensadon,
will do the work,and thestrueture Is wOntantled ar OBeml fomale(Sec.7044,Business Required Inspections
and Pmfrsslors Code:Th Cmumnonsme ns
fs License Law does lot apply an Owner of q P
property who bolldsorimpovea thereon,and whodassuchwmk himself"thmugh his
own employees,provided that such lmprovemenu are noUnunded oroRered(orale.if.
however,the building or improvement Is mid within on year of eompledon,the owner.
builder will have the burden of proving But he did not build m ImProw:for P.M..of
ala).
❑1.as owner of the property,am excluslvely contow ing with licensed contractors to
consumer the project(Sec.7044,Business and Professions Cade:)The Canoacmr.Lb
cense Law does am apply to An Owner of property who builds or Improves theater,and
who contracts for such projects with a eomrmur(0 licensed pursuant to the Contnnor'a
License law.
❑1 am exempt undo Sm. .a A P C for this¢seen
nes
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury am of the following dedso lens:
❑1 Mara and will maintain a Ceninnle of Coment IoselFlaure for Workcr'sCwnpen.
mlan,As provided for by Section 37011 of the labor Code,for the prfam.ace of the
work for which this permit Is issued.
(:11 ham and will maintain Worker's COmpensallOP Insurance,As required by Section
3700 of the labor Code,for the performance of fm work for which this Permit is issued. -
My Workee,Cn�mI'��aaOo(n/ln/conn carrier and Policy number au: r�
Cartier.Al�s(7m S Polity No.: i4 OC f
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section wed not becompleted ache prmil Is Intone hundred dollan($100)
or leu.)
1 certify that In the performanco of the work for which this permit is Issued,I shall not
employ any person In any manner sat As In hecoma subject to the Worker'Compensation
Law.of California.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Cenifica¢of Exemption,you stu W
bocome subject to be Worker's Compewdon provisions of the Labor Code,you must
.JO forthwith comply with such pmvlslom wlearned
this permlt.holl m rawked.
zs14 CONSTRUCTION LENDING AGENCY
fw Ibounty affirm that thane is A constmctim lending agency for the performance of
the work for which this Permit Is Issued(Sm.3M7,Civ.C.)
Q lander'.Name
z Lcnder'AAddmaa _
U 0 I certify that I haw read this Application and sure that the about Information Is
B.F correct.I gree to comply with all city and county ordinances end sum laws rearing 10
0 V building construction,and hereby mhmine mpruenulins of this city to enter upon the
If7 ahow-mentioned properly for inspection Purposes
n. (We)agree to use.indemnify and keep harmless the City of Cupertino slinu
rn liabilities.judgments,eau and expenses which may In my way accrw against sad City
()7 In cons
equenceing of this permit.
rte— APPLD ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR
Re-roofs
Slgnauor Data
RDOUS MATERIALS DISCLOSURE Type of Roof
t future building occupanalore N handle heardous metrial
a defio Municipal Coda.Chapter 9.17,and the Health and Safely
^ode,Section 25532(°)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Q(No
Will the applicant or future building oaupm use equipmcol or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haardmua air cone nhomm As defined by the Bay Aro.Air Quality Management all new materials for inspection.
Dl.trin7 �k[[
❑Ya Nis.
I have mW the lu7ardtwa material,ruquiremanta under Chapter 6.95 of the Califor.
nla Halm&SafetyCode,sections 25505,33533 and 25534.1 understand that,lfthe building
Jnes not cunt ave a umml.that It b my ro.pnsthility to notify the occupant of the
rcyulmma wh' muubc tp nohm ceofAC0 Oc pVcy. Signature of Applicant Date
Owner era ,< Dta All roof coverings to be Class "B"or better