08080061 CITY OF CUPERTINO
BUILDING DIVISIONPERNIIT CONTRACTWcINFURMA.T I(
BUILDING ADDRESS: PERMIT ND.
? 0501. N PORTAL AVE DOUG PARISH CONSTRUCTION 08080061
NEWS NAME: PERIM ISSUE DATE
MUHRAY W S AND SUSAN H 14590 BRONSON AVE 08/08/2008 -
-PIIONE: SANITARY NO. CONTROL NO.
ARCHmiCffENGINEER: BUILDING PERMIT INFO
REMODEL KITCHEN (E,M) BLDG ELECT PLUMB MECH
0
300 LICENSED CONTRACTOR'S DECLARATION Job Description
d I hmaby affirm that 1 am Hen¢M under provisions of Chapter 9(commencing
nz1 with Section 7000)ofDivinum 5 ofthe Budrcsr and Profusions Cade,and my licensota
in full forte am effort
j b Z License Clue IJe.I
e Date Codtmmn,
e9 ARCHITECTS DECLARATION
y 1 understand my pians Nall he used an Public records
J U
yd.
Licensed Proressianel
OWNER-111.111-DER DECLARATION
I thereby mour.(term o n I 01.examPl from the Conhact.o e:Any
Law far the
D following u mourn.(Schon]0313,Businessernand improve.
the ons Code:Any city as county
3 which rtquims a permit nu tnnsWc4 aper.bnmave,h Permit t or mash any atmcwm
miorbita issuencc.alan requires tie Tpplkanlfor Such Permit to fik a.igmd mumant
y� c wt W is licensed Im 1 Tum proviaonsofne canuncmra Line.Law(Chapter 9Sq.F1. Floor Area Valuation
low....Ing with Section 7000)of Division 7 ofthe Dust.W Prorudons Cade)or
than he is exempt Oemfrmn and the bub for the aliagrA eaempd..My io alwo of
Section 703 1.5 by any applicant for a Permit Tubjecta the applicant to a civil penalty of APN Number Occupancy Type
not mart than Bw hundred dollars(S500).
❑I,uownmof the Pre trio mmYotime ie with xgdeuthe'vseke .B"don.
will do thewmk,tad the Thecae h mors Li ens or offered role Includeapply Todd,Basi.
and Profusions Cade:The canhacmrt,acme Law does not apply if an Dorso of Required Inspections
property who s,pmviimprows Ih improvements
and wW sums omhw tied!woelr eddaough his
awn empl.yeex,proMded pr tmhimprovemantaau not earofdmoRemd Tar owner•
hulkhor ,,Ne building m improvement b told within oro year of o.mole for the owner.
of
Wndm veep Mw the buNan of proving Nu K did net build or improve far purpose of
ark.).
�gt.I,u owner or the Property aro exclusively comeuYiq with licensed cnhactma to
mnsuucs on,project(Sm.TON,Bui.and Profnssions Cade:)The Contractors Li.
«ve law dons not apply to an owner of progeny who buiWa or imuoves Woman,and.
who conuacu Antioch projems with a cnhacurts)liceucd pursunt in the Contranors
1.1cmad law.
❑tun exemtun (Bee BA P,C rim reason
mr r iw_ Dau
WORKER'S COM ATION DECURATION
_ I hereby affirm under realty of perjury am+or 0m following declanliau:
I ham and will maintain•Cesslncemoiconsenuo self-Imam for Warkm's Compen.
sulor,as Provided for by Section 3700 of the labor Cade.for tie Performance of the
work for which this permit is issued.
Q 1 have and will maintain Warizes Compmemdon Insurance,u required by Section
3700 of the labor Code.for the mrformance of the wank for which this permit is Issued.
My Workers Compensation Insmaus clnici aM Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This seNan ted nmhecompked If the i mmil la rorome hundred donars(SIM)
or Ides)
1 certify the,in the Performance of the work fm which this Permit is issued.)shall not
employ any person in any muncrm tau oYlb wpm do Worken'Compenudon
Laws or ;APPLICANT.
. i .Da a I
NOITCETOAFPISGNT: ' normoldingsCertiOuu the
Ulan,on,yonshould
become subject y the WoheYa Com s or Ow pmHtimai of tie labor Code you most
,J O forthwith comply with omit provisions m Nb prnnit Nall W dcemW rewtW. '
'�y CONSTRUCTION LENDING AGENCY
[..t I lemhy,aBbm that then is a mnsmun(nn holding agency forme performorie or
C w�a
the work for which this permit is issued(See 3097,Civ.C.)
W Q Lenders Name
Lenders nders Add.
U Q 1«Nfy,that 1 have mad this aPOkm..and sou that the aWm information L
W^
correct.I agree in comply with all city and county indictments and sum laws minding In
SV^ building construction,and hereby authoden representatives of this city to enter upon the
W Thaw-mendamd property for inspection purposes.
(We)agree to ave,indemnify and trop hornless the City or Cupertino against
wy y
liabilities,judgments.ease end exismumt which may In any way terve agalmi.said City rat
(„)7 in conqueror ar the g,uhng of this Permit.
r7 APPLICANT UNDERSTAND$AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER!� LA71pNS/i/] C/
ti ���N L� Re-roofs
Sigou rt of ApplicanOCOem cmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof /
Wil the appilann or rumor building oecupann uom mlundle havNou maedal
u dented by the Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
.Sued..35531(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yen j_Na
Will the applicant or future building occupan,use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
coup h.vard u.at,....I...U u den.od by the Bay Arta Air Quality M....co e., all new materials for inspection.
Dinric,i
QYu IQ—No
I haw mad the hvsNmu mamriaumquiremenu mom ChaPeS6.95.fthe Califur-
m.Health At S mlYC.de.Seedms23105,15533 uld25534.1 understand dW ifthe Wilding
does not mormfly have a tang that it b my rdepaoMlhy in notify the common,or the
mqulrtnen whish mow k ar lo issuaite o(a Cvlifiuu of
Af , 4 Signature of Applicant Date
47 S`g G ��p 0 All roof coverings to be Class'W'or better
Owner onmhodmd agent Dau