04050049 CITY OF CUPERTINO
BUILDING DIVISION PERMIT LCONTRAC�°TaRINFORMATI'ON
R
BU ILDING ADDRESS: RAWSON CONSTRUCTION PERMTTNa4050049
OW NCR NAME: PERMIT ISSUE DATE
2004
E: SANITARY NO. CONTROL NO.
(408) 377-0600
ITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTOR'S DECLARATION
0 0 0
zA I hereby affirm that 1 em of
Bi under provision of Chapter 9(commencing Job D J.i 01t,�L E D
n� with Section 1011U)of ivlalon3of the Businesand Profeoinn Code,end mylkenec is N
infant dere -^ '/
j�z
Licari. era Lle, Of;J • KITCHEN & DINNING REMOD
DAM �\ Conuaclor
ON
I undesess.6 $"PlansMali he uredo vin. arch
roCTS D
12 NOV Dt 2004
3 Licensed Professional
Oe,I me exempt
from
DECLARATION w
ED f 1 hereby mixe .(firm than 11. exempt s m the Conlon o License Law for the ■J 1 'I 1 D I p 1 �0 O O
O O following maven.(Section 7113 Lq Business and rre. a moll Code:Any tiny I county vR U L I`V■
$ which its requires issuance,penin m e inumen alms improve,h Permit I or n pair hay avocm i
F Z i pdm m ie coseprsues man oqulrn thrpro a provisions
n for Com emniuo ble se Law(Chapter
thathelicenadPursuanttotheofDisi000fNeCanuamfilucmclammiCo mr9 Sq.Ft. Floor Area Valuation
thus,W exempt mato,and t f haps,fix theof al Buseged casapt ons.Myavi Axle)of
tint io u 31.5 b 0ertfrom and the Ease fm the alleged exemption.Any l Pennon of
Semon than five
as9 applicant Int a permit subjects the applicant m e civil Penalty of 3 2ab"INN&IS ye10 0 Occupancy Type
not mart than five hundred dollars lssOOL P Y YP
0 I.as owner of the property,in my employee with wages as their sole compensation.
will do the work,and the swmum 0 out intended or offered for sale(Six.7044.Business
and Professions Code:The Contractee,License law does rot apply to an owner of Required Inspections
pmpeny who builds or im proves themon,and who dors s uch work h imself or through his
own employers,provided Nu such Improvements are not Intended"offered for ale.If,
however,Ne Wilding or Improvement iaald within one year of completion.the ownco-
builder will have dM Wtdcn of proving than he did net Wild or improve for purpose of
ale.).
❑1.as owner of the property am exclusively contracting with Ilceaad convectors no
convect the pmjett(Sec.7014,Business and Profession Code:)The Convector's U.
come law dors not apply in an owner of property who Wilde or Improv thereon,and,
who contracts for such pmjeco with a contra um(s)licensed pursuant m the Convector's
,Lpnes Law.
tem exempt under Sec. ,B&PCforthis moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby afOm under penally of perjury am of the following dedantion:
have and willno" oma Certifnwof Cotuentma141nsum for Worker's Campem
n,as provided for by Section 3700 of the labor Code,for the performance of the
for which Nis pcmil is issued.
1 have and will domini t Worker's Compensation Insurance,o required by Section
3700 of the Labor Code.for Ne anti mance of the work,for which this permit is issued.
My Worker's Compensation Inmrice carrier and Policy number are;
Po_liss77tt o.: _
CERTIFICATE OF EXEMP'WS UR ORKERS'
COMPENSATION1iFFffSURANCE
(nU=tim reed not bocomplewd if the permit Is forone hundred dolWa($101)
or loss.)
I certify that in the performance of fee work for which this permit is issued.I shall not
employ any nm ym lace, 3Vbjacnothe War ri Compensation
Laws of Ce �3 y'Jsr
11
NOT IC rAPPLICANT.If.afwr making Nis Cegifieem of Exemption,you mind
become I=m the Worker's Compensation provisions of the Labor Code,you muco
.,O foMwiih comply with such pmviMom or Nis pcmit shall bo dmmcd mmked.
z'-" CONSTRUCTION LENDING AGENCY
4 I hereby affm Nat them is a coeswNnn lending agency for the perfumace of
> the work for which this permit is issued(Sec.3097,Civ.C.)
A Lender's Name
Q z Lender'sAddress
O Q 1 certify that I have read this application and scow that the main information is
D.Fcomet I agree in with all wall city and county aNinances and some boo,misting to
QU building construction,and hereby audonse representatives;of this tiny in enter upon the
W above-mentioned pmpeny for inspection purposes
gyp (We)agree to ave,indemnify and kaop mommas the City of Cupertino againt C
IA
liabilities,judgmene.core and expense which may in any wayaccrue against aid City \ '
U,Z in consequence of the grann o o This permit \'
A NT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
0 REGULATIONS.
/6 f-- S'%D-O Re-roofs
grown ofAPPlicanVC n ter Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the epplicann or future building asupat mom or MMIe haudom mewdal
u defined by Ne-Cupertino Municipal Calc.Chapter 9.13.roti the Health and Safety
eWe.section zss32(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes YI Nu
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
it hoardoa air co mord...0 a defined by the Bay Ames Air Qualify Management all new materials for inspection.
tricR ��xJ/
❑Yes mNu
1 have mad the husendtmsm nnialsmquimments under Clupwrd.95 of the Calirm-
di NmIth& afctyCodc,Seation25505.25533 aad25534.1 understand WtifNC Wilding
does twt c ly have a Mason the it"In
mspotuiht toy to n 'fy dw occupant of the
require. a g(Jhcr�ustbcme.pnorm's ofaCerdnew cu Cy. ignature of Applicant
Date
X�TI�LGY/ Q,IGh � All roof coverings to be Class "B" or better
O ro motorircd agent Dam g