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BUILDING DIVISION PERMIT
CtUl`ITRATORINFMATIN
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FCYTTY
DINGADDRESS:
CONSTRUCTION
PERMITNo.05090224
133 PARISH PL
ER'S NAME:
PERMIT ISSUE DAZE
MARY SCHIFFMAN
2593 HEBRON AVE
09/30/2005
4E:
SANITARY N0, CONTROL NO.
(408)274-6799
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTO PO MFCH
O
LICENSED CONTRACTORS DECLARATION
Job Description
o
I hereby affmm Nat 1 son licensed under provisions of Chapter 9 (commencing
with Section 70(10) of.1 ion Softhe Busirmsa anQPro(caluu adgand mylicene is
in full forte and e0m 3
REMODEL KITCHEN/BATH,
INSTALL BEAM -NON STURCTURAL
Dau C onuacWr s
ARCHITECTS DECLARATION
I understand my plans shall W used u public rccmd=�.. e'
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby emrm Net I theexempt foam the ContraclYra License Law for the
fallowing mason. (Section 7031.5, Business and Pmfeuiuu Cade: Any city or county
which requires a permit to ennwct, alter. Improve, demolish, or repair any stuelum
prior to las issuance, also requires the applicant for such permit W file asigned suumem
Sq. Ft. Floor Area
Val i
e Concusrs License Law (chapter 9
Net he is licensed pursuant to dm provision of Nua
(commencing with Section 7000) a Division 3 of the Business and Profusions Code) or
Nn he m exempt therefrom and du basis for Ne alleged exemption. My violation of
ppb �.7 �y
Occupancy Type
Section 7031.5 by arty applicant for a permit the applicant W a civil penalty of
nor more tan live hundred dolWs (M),
31 b 4 4 BT §e, 0 0
❑ I.uownerof Nepmpaty.mmyemploymwiNwgesu Nebanlecmnpe don,
Required Inspections
willdo mut.&.aed thesuuctme is mrsam(Sec. 7044, Business
and Ptofessums Cade: The Connectdon not License Law donot apply Wan owner of
9 P
property who builds or improv thereon, andwhodceasueh work himaelfor through his
own employees, provided drstsuch Imprmemenu tee not intended woRered forssle. If,
however, the building or Improvement is said within one you of completion, the Owner.
builder will have the burden of proving Nat M did not build or Improve for purpose of
sate.).
❑ I, as owner of the propenX am exclusively contracting wide licensed contractors to
construct the project (Bee, 7044, Business and Professions Cede:) The Comacter'a U-
cenu law does not apply to an n'a'tter of property who builds or impmvo thereon, and,
who contncu for such projects with womractor(s) ficeued pursuant W the Conuacura
License Law.
❑ Iameamptundu See ,B&PCfm Nisn%Um
nr Dau
WORKERS COMPENSATION DECLARATION
I hereby affbm under penalty of perjury aro of the following dechandou:
I haw and will mainsain a Cenifrcat, of Conant to el6luum for Worka'sCompen-
mion, u provided for by Secdon 3700 of the Labor Code, for the performance of the
woh for which this permit is issued.
❑ 1 have ad will maintain Workers Compensation Insurance, u required by Section
3700 of Ne Labor Code, for dm performance or the work for which Nie Permit is issued.
My Wor i Compev on I .ot c nme, and Policy num r art:
cam Policy No.:
CERTIFICATEOF EMP ION FROM WORKERS'
COMPENSATION INSURANCE
(f bis section need trot be can plead i f the permit H fn one hu^dmd dollars (SIM)
or less)
1 certify Not in the pcohmeacce of the work for which this permit is Issued. I mail not
employ any person in any manner an as W became subject to the Workers' Compensadon
Laws of CsiBomla. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate 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 he decreed revoked.
CONSTRUCTION LENDING AGENCY
I hereby efiir a that Nem ins couuuction lending agency for the perfmmanceof
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Lender's Name
Lenders Address
I mnify that I have read this spplicnd. and sum that the show, Mramosti. m
correct. I apo W comply with sit city ad county ordinances and sum law remain{ u
Wilding construction. and hereby mmorhm MPTUR miws of this city W enitt upon the
show -mentioned pmpcny for inspection purposes
(We) ague W saw. indemnify and keep harmless the City of Cupertino against
luthi Wes, Judgments, cuts and expenses which may In any way accuse gainn said City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SO 'fin
UgfGpLATI(I
Re -roofs
Type of Roof
Signaturcof Applicant'Conuactor Date
HAZARDOUS MATERMS DISCLOSURE
Will the applicant or future Wilding oceupantSWM or handle hazardous material
as defined by the Cupertino Municipal Cade. Chapter 9.12, and the Health and Safety
ode. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
0YuNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant of future building Occupant esu equipment artleviw which
mit hnatdous air contaminants as rkfined by the Bay Amo Air Quality Management
all new materials for inspection.
District?
❑Yes u
[have mad Ne hmardousmawHammquimmeno unde,Chapwr6.95of Ne Califor.
-
niaHulth&Safety Cad.,Sccdou25505.35533md25534.Iundcmmd NuiflM molding
does not currently haw a u mm, that it is my responsibility in notify tho Occup n, of the
royfaC 111es r span
U C
Signature of Applicant Date
M=�
All roof coverings to be Class "B" or better
owner or authorized agent Dam
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