06050045 CITY OF CUPERTINO ' ='
BUILDING DIVISION PERMIT CdNTRACTORI_,ORMATIOIY-3
BUILDING ADDRESS: t INTERNATIONAL KITCHEN EXCIKfffftOO6050045
19975 PRICE AV
r' "R'S NAME: PERMLSBUE DATE
POCIT HYLSKI THOMAS T AND KAT SH1175 E HOME
_ QS/04/2006
PHONE: SANITARY NO. CONTROL NO
(408) 296-3055
ARCHITECr/ENGINEER: BUILDING PERMITINFO
BLDG ELECTPLUMB MECH
C= E
� . 0
:og LICENSED CONTRACTOR'S DECLARATION Job Description
wC
F I WmbY affirm Wt 1 am Recanted under provisions of CM1aPter 9(commencing P
tZW with Smdon 7U(IU)of Division l.fCo Businev and Profession Codc.antl my license is
?�N in full folec and effect KITCHEN REMODEL MINOR STRUCTURAL
7 o. crnacNr REPLACE 1 DINING ROOM WINDOW
ARCHITECTS DECLARATION
1¢< I undcmund my plans shall be used as public menrds
yyU
Licensed Professional
3 OWNER-BUILDER m the Com ION
C 1 hereby alarm on I em eacmpt s ad the Canlnnors License Law for Co
p O following tenon.(Section](D 1.3,Business and improve.
de nn Cods:Any cm or county
Sm which rcqusn a permit re cnnspacl.alter,Improve,h permit t or e a sisvumurt
primes its censedeameard ondisCoapionso for suchpmmiuoicenssigned statemem
p€O Wmmenccwucd pursuant told previsions of use Contractor's Law Coplm9 Sq.F[. Floor Area Valu1311816
e (commencing wiNSmuon70ndha mid,for of the Business add Profession Code)of
y��
that be u earmpt Nme(rom and Co buss for W alleged ewnptian Any violation of
Section 7031.5 by arryapplicant for a penis mbjecu the applkant his civil penalty of APN Number OccupancyType
not more Nm few bondted d.11ars(g ). 36905040 . 00 YP
Q 1,as owner of lbe Property,Or my croph,'"with wagn v then is compensation,
will do Co wodtandCo swcturt u not intended m.ffer d for We(Sm.7014,Business
and Pnfesdan Cade The C.nuxtors License Law don oat apply to an owner of Require Inspections
progeny who builds or improves Cormn,and woo does such were himself m dunugh his
own employees,provided Nat such improsemmis art not intended Or offered forsak.If.
builder.Co building or improvement u sold within net
year of improve
for the owner-
buildcrwill have the Wrtlm of proving that be did cot build m improve Isar purpose of Q
sok.).
❑L ne.weer.!Co property,.B eulusivdd confessions with Iicemed mnmemrs U.
conuum it p not (See.7W.in Business sed Profession Code:)The,ConOamon.Lid
who c taw don not apply je an hat of property who Wilds p ar improves Corton.and.
whomnsracu for sled project what pumummlee Conuactors
❑Idm acmes unhr Sec ,BAPCfor sou rtason �O
r Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Porosity of perjury one of Co following declaration:
Q 1 naw dna veal maintain a CutiOmte of Camcm m self-inurt fmwartehcompm-
waft for
which f far mi Section 3700 of Co Labor Code,fm Ne peRormartce of the
waft for which Nis permit is inued.
❑1 have and will maintain Workers Compenatian Insurance,as required by Section
37W.fCo labs Cade.for the d...f the work far which this permit is issued.
My Workccess Compensation Invertase canicrand Policy number arse: G ^I
Cartier. Rl[ �1 4 icy N..:P"Ir/OZ h3 1
CER FTCATE EM ON FROM WORKERS'
COMPENSATION INSURANCE
(Dasa seNon sed not be completed if the pensit is fortune hundred dollars($10(y) v
nr kss7 ,
1 certify that in the Mr...of W wort for which this permit is issued.l slut)not .
employ any person in any marrncrso as in become subject N Co Worters'CampennYon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after malting this Certificate of Exemption,you should
become subject to use Wottch CoreaXa ation provisions of the Labor Code,you must
.J z forthwith comply with such Pwvislan or thk Permit shall be dmmcd tewicc 1.
z Vy CONSTRUCTION LENDING AGENCY
(-+ I bereby affirm dust Wm is a mwmnm.lending agency far the pcdermades of
F4 ti the work for which this Permit es Wood(Ser.3097,Civ.C.)
6W.a) Undies Name
7 z Lendera Address
U Q 1 certify that I haw mood this application and sats that Co aWw informadun is
U. comect-I agree to comply with all city and county or inantta and state laws relating N
0 V building convection,and hereby authome represenudves of Nis city 10 enter upon Ne
Ct7 above-mentionedproperty forinspection
whichpurposes,
t„s 0. (We)agree to eve.indemnify and loop harmins W City of Cupertino against
rn incaitin,judgmcnhecola and npcnspc which may in enY way act¢againuaid City
t.)z Acnnse ANT ofCogranting or this WIL —
^ APP 1 ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date , O�
50 REGUy�Ot�S.� (� ', W
wog( l/gS•f{/1 dlloa �X11'S 1 Dole � Re-roofs
Stgouurt of App taHAZARac Date
HAZARDO SMA7TRIAISDISCLOSVRE Type of Roof
Will Co applinnl or tutu¢Wilding aavpmsmom or haMle hanNon materiel
del I by Co Cupeelm Muni i Cads.Chapter 9.11,and Co Health and Safety
Section 15531(.)? All roofs shall be inspected nor to an roofing material being❑Yrs Na P P Y g g installed.
Will Co applicant or future Wilding oceupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havard.n air lintaminnle as de6¢d by Co Bay Am.Air Quality Mangcm.nt all new materials for inspection.
District?
Ya u
1 have read the Woodous materials rtquiremew under Chapter6.95.fCo Califon
'a Heah"SafnyCode.Stti
155115.15533md255M.1undcrsund Nmifde Wilding
decd cunen I haw a tena II u my mspmudility m unity the eccupnt of the
rt Wena, orwiaw emiricate OC any. Signature of Applicant Date
(�{ — All roof coverings to be Class "B't or better
Owner or suNarimda rat Unto