08060049BUILDING DIVISION PERMIT
YCI(MI I IV
eulLgltic.npgR PV.
ARLETT PL TBD - TO BE DETERMINED 08060049
NER'S NAME: PERMIT ISSUE DATE
CAROTHERS W D JR AND MARY A 06/06/2008
HONE:, SANITARY N0, CONTROL N0.
ARCHITECIyENGINEER:
u p p LICENSED CONTRACTOR'S DECLARATION
rd F 1 Mmby affirm Mal 1 am licensed under provisions of Chapter 9 (commencing
with Section 7") of Division Jafde Business vyDprof ` ryC Mmylicenseis
o, in full forte a 6 L6Jf --12r
j = Lcesrc Lac. g
V q m Con
DaDEC
�ppied As Malt use DECLARATION
k V dcnunJ my phos shall be used u public raords
g G H Licensed Pmfcutoml
3OWNER-BUILDER DECLARATION
s� M 1 bemhy aRrm that 1 am exempt from the Contractors License Law far the
Cp O following ]won. (Sadao 7131.5. Business and Professions Cade: Any city or county
Sm which mquims a permit W c mu rucL Mon. improve, dcmNuh, or mpsir try Sttructure
it prior to its issuance. Alan requires to applicant for such permit to file a signed sutemcnt
pp < that he is licensed pursuant to the provision of the Com acsin's License law (Chapter 9
Y~$ (cammencingwiN5cdon700B)of Division7ofthc Businmand Profmiam Cadc)or
this be u exempt Ocrcftam and the basis for the alleged exemption. My violauan of
Section 70313 by any applicant for a permit Mbjecu the aPPoanua a QVll penalty of
.1 mom dlu fiw huMrtd dollus (M).
I,uowrer of IIIc pmpcny, or mY employees with wages uthe'vsek compewtion,
willdothcworkanddteslructumiarmtWmndedseraRamdr.s (Sa.7W.Business
and Professions Code The Contractor's Lacune Law dart Out apply W an owner of
property wW builds or imposes thueon. and who docs such work himselfor lhmugh his
own employes, provided that such imprommems secret intended or offered torsade If,
bawem. the building or improvement is roto within arc can of cosapktion, the owner.
builder will have to Wrden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of to property, am exclusively contracting wit licerued contraclam to
constmct M project (So- 70 , Buinm aM Profession Cade:) The ConaacWr's Li.
acme law does not apply as an owner of prope, who Wilds or improv thereon, and
wed aonaacs for such pmjcm wit a conuamor(s) licensed pursuant W the Conuaeats
License law.
❑ lameaemplundrs See ,B&PCfmdri1,awn
mer Dam
WORKER'S COMPENSATION DECLARATION
I hereby air= under penalty of perjury arc of dte following dalersans:
❑ I ham and will maintain a Camficamaf Cmuenuo self-Wum for Workers Compm.
scion, u provided far by Section 5700 of the labor Code. fm to perfmma. of the
work for which this permit is Ismax.
1 ham and will maintain Weathers Camprnulinn Insurance, as lequircd by Seedon
77W of the labor Code, for the Nsfarmance of ted work for which this permit is issued.
My Wmloe C peneatian rano cartim and Polity number�sart:
Cartier. g•_aaL.0 giGfl rL� Policy No.: K I k I a.J 57-1,
(Thu seminar bend not a compacted if the Permit is far ane hundred dollars (SIM)
or leu)
I cemufy ]hat in the perfma ane. of the work for which this permit u issued. I shall not
employ any person in any manner an as W become subject to the Workcri Compernation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. If, after making this Cedifcam of Exemption, you should
biome subjat us the Workers Cana mssum. pmWiom of the LaWr Caen, you mon,
.J aZ foMwith comply with such provisions Of this permit shall be dcemcd remkcd.
z 0 CONSTRUCTION LENDING AGENCY
[-+ I emby, affirm tau sem u a construction lending agency for the pMformanceof
lyi 7 the wish for which this Permit is issued (Sec. 7097, Civ, C.)
I2] A Lendeh Name
Z Lenders Add.
U 0 1 certify that I hats: read chis application cab slate that to Mass information is
t2a P cornett 1 Rice to comply wit all city and county ordinances am sum laws mloong W
0 Wilding conssucsian, and hereby autharies repmmnudas of an. city W enter upon the
movc-mention cal property for inspection pm,mes.
H 1
(Wo) agree W sass, indemnify and kap harmless the City of Cupertino apinst
^ f/] liabilities,Judgments. cases and expcnsu which may in any way accrue against said City
(„) Z in consequence of the gnnang of this permit.
^ APPLICANT UNDERSTABDB{,ND WILL COMPLY WITH ALL -NON -POINT
9.41V. A'11omracWr Dabs
HAZARDOUS MATERIALS DISCLOSURE
Will the *pit=, or future Wilding occupant some or handle laborious material
defoed by the Cuper ince Municipal Code. Chapter 9. 12. and the Health and Safety
de. Section 25572(07
❑Yea a
Will ft applicant or Tum Wilding savpant use equipment or devies which
tit haeafdou air contaminants as defined by to, Bay Am Air Quality Management
swim
❑Yca ;'o
I have read! the
le
nV
ADD NEW CABINETS I COUNTER, ' BLDG ELECT
G4;NK, ABE) 4: SINK F-AISP O O
.Job Description
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date C
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 'W' or better