05040044 CITY OF CUPERTINO
BUILDING DIVISION PERMIT gzUNTRACTOR INFORMAT ON
BUILDING ADDRESS: PERMIT N0.
05040044
O NE AME: FERMITISEUEDATE
E; SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB Ma.CH
t� I�
80 0z LICENSED CONTRACTOR'S DECLARATION I]Ob Description
I lemby affirm that I am licensed under provisions of Chapter 9(commencing P
with Section 7")of Division 3 of the Business and Professions Code.and my Victim is
In full farce and effect. /s0-FOCt9
5't3? LlcenseCIAn LIc.N E KITCHEN REMODEL/UPGRADE ELECT. (200AMP)
Dam Contractor,t� yL
ARCHITECTS DECLARATION CONTRACTOR: ALLWAYS N
My 1 P101understand my plans shallbeused u
tlpuNic meatus
m/Ar\`
p
3u. LLicensedPndession,l
OWNER-BUILDER DECLARATION I L
d<2 I hereby affirm that 1 em exempt from the Contrmrof;License law for IN
O
O following ngmuon.(Section 703 I.S.Business and Protestant;Code:Any city or County
$ which requires a permit to construct,ser.Improve,demnlim.or repair any structure
pdormssissuance.alanrequher the applicant retouch permit to file ulgned statement
gp < that he is licensed pursuant m the previsions M the Comr¢mr's License iaw(Chapter 9 Sq.Ft. Floor Area U.7 Valuation
8 (commencing with Section 7000)of Division 3 of One Business and Profession;Code)or
33 Nu he is exempt Ommfrom road the bub far the alleged eumption.Any violation of
Section 7031.3 by any applicant far a permit subjects the applicant in a civil penalty of APN Numbe Occupancy pe
not mane:Kron five hundred dolbn(SS00).
❑1,As mvner of the Property,w my employees with wgas As chair rule compenuRon,
will do the work,and the su num Is not inuaded or offered for sslo(Sec.7DN.Business 37542049 . 00 Required Inspections
and Profenaions Code:The Coruscate,License Law data ree nst apply to an owner of q P
property who builds or improvestheman,and who doeuuch work himaifor through his
own employees,provided Nat such Improvements are not amended"ofered roreaie.If.
however,the building at Improvement is mid within one year of complealm.the.ween
builder WIR have the Wrden of moving that he did not Wild or Improve for purpose of
use.).
❑1,as owner of the property.am exclusively contracting with licensed contraction m
construct the project(Sec.704/,Business and Profusions Code:)The Cenuamr's Lt.
cense law data not apply to an owner of properly who Wilds or Improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Cantraor's .
License Law.
01amexemptunder Sec. ,B@PCfm M1snoon
Owner Date
10 WORKER'S COMPENSATION DECLARATION
1 hereby Mm under penalty of perjury ane of the following declmidons:
❑ I hive and will maintain a Cerdfcam of Conant to self-Insure for Worker's Compere
nation,As provided for by Section 3700 of the Labor Code,for the perfotmmm of Ne
work for which this permit Is law.
❑1 have and will maintain Worker's Compensation Instant=.as required by Section
7700 of the Ulan Code,for the performance of the work for which this permit is issued.
My Worker Cemptmtlonelnlmamrax,CA end Policy numberrm s�
Caller. /2(fp/�/JV/It/7 Policy No.: Q�s O�O4oI3I
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This mmim nerd ml he completed NOW permit life,.hundred 011.(SIM)
Or less.)
1 certify that in the performance of the work for which this pc cad,Is issued.I shall not
employ any person In any manner an as to become subject o the Workers'Compens Pian
Law,of California.Doc
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject to be Worker's Compensation provisions of the lahor Code,you most
,J O forthwith comply with such Prnvbpons or this permit shall he deemed rooked.
CONSTRUCTION LENDING AGENCY
t—r Ihereby affim the,them is a contraction lending agency for be perfcemuwt of
DG IW work for which this permit is issued(Sec.3097,Civ.C.)
Q -a-'.r"mo
Q z Lender's Adtlnu
U Q I certify that I have rad this application and state that the AWve information Is
Iy F correct.I agree to comply with all city and county ordinarees and mile laws muting m
OU
Wilding emsuucdon.And hereby amhodxe mpmbe
sentuiw of Nis city,.Color arms
W above-mentioned property for inspection puNema
0. (We)agree to save,indemnify ad kap humpeu the City of Cupertino against
„yy IhblVlties,judgments.core and expenses which may in my way same Against aid City
V 7 In consequence of the gremingof this Permit.
Fl APPLICANT U E TA SAND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOU BRED A NS� ,�
s.
/I /_ J'off o) Re-roofs
Signuurc of ApplicmVCem ser Data
HAZA DOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future Wilding Occupant owe or handle Includes,material
As defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
IOn
Section 25532(a)T All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
WIII the applicant or future Wilding Occupant use equipment or devims which
If a roof is installed without first obtaining an inspection,I agree to remove
ha'Ardom sir conuminan s u defined by the Bay Amro Air Quality Management all new materials for inspection.
❑Yes ❑No
I have mW the hnarthms materials mquimmmts under Chapter 6.95 or the Califon
tlth k SatmyCdt,Sections233f13,23577 and 25l74.I uadentsnd the0f Inc WIIJing
not y ave aL mfret h is my responsibility to notify the occupant of the
rements mMtht metpdorMiaroumaorst eu+arOccupangg/ Signature of Applicant Date
A L Vol °
ownetermthad.<e.gen D,m All roof coverings to be Class"B"or better