03030166 CITY OFCUPERTINO
BUILDING DIVISION PERMIT ,CO �' UX2N 'U�vt .' `
€ n«' .fit m .• xr k'AT
BUILDING ADDRESS: - PERMITNO.
CUPERTINO KITCHEN DESIGNS
OWNE PERMIT ES
10562 S DE ANZA BLV
SANITARY OL NO.
(408) 257-4900
ARCHITECr7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT- PLUMB MBCH
ij OO LICENSED CONIRACTUR'S DECLARATION lob Description
I hemby a[Orm that l em licensed under p v)tiana of ChePWr 9(commencing p
wINSection7dp)ofDi,Won3ofIMBusi., u Pmrcuimu Co@,sntlmyIiuveH
lot react ane t.� T 3 REMODEL/HALL BATHRM'
dense Clw r Co « t z, I hit) rC
ARCHITECTS- RATI N rj /�
1 ndenuntl my phos ah.11M=it u public rernrds __ /-) I
5 Licensed ProfcnionJ /,9/
OWNER-BUILDER DECLARATION ``, u
.�t E 1 hereby aRiran the,I am exempt from the C.tramors License Lew far the
p O following mosso.(Seeti.7031.5.Business and Pmfcations Cade:Any city or county
2 which mquhm,a Penni,W construct.alter.Improve,demolish.or repair any nmemm i
Fain rdmWits issuance.alw acqulmsthe applicant forsuch permit to rite a signed moment
QQQ C that he is licensed pursuant to the provisions of Ne Contractor's luenselaw(Chapter 9
$ (commencing with Section 7000)of Division 3 atte Businessland Prokasinm Cotle)or
Wt he is exempt therefrom and the basis for the staged exemption.Any violation at ��t��tt h��
Section 7031.5 by any applicant for a permit objects the applicant to a civil penally of 3�'L3 YdT-Ir 00 Occupancy Type
amt mom than five hundred dollen($500).
0 1,as owner cribs property,many employees with wages u their sok caanpema ion,
wllldo the work.and thestructum ts ave,intended or offered forasle(Sm.7041,Business actions Ins
and Profession Cade:The Oa W*Ws Liceme law don nor apply te an comer of 101 — FOUNDI$&Q�d p
pmpenywhobuilds orimpmvet therean,and whoduessmhwork hlanselfor through his 102 — PIERS
ovnemployces,Provided that such improveane ms are no,intended oroEered forsak.IL
however,the building or lmprowmestis sold within oro year of completion,the ower. 103 — UFER
Wilder will have the burden of proving that he did not Wild or improv for purpose of 104 — REBAR
Dl,as owner of the property,am exclusively contracting with licensed eontnmen,W 105 - ANCHOR BOLTS
construct the project(Sec.7010,Business and Profoutiom Cade:)The Contractor's U- 106 — SEWER & WATER
came law dam not apply W an owtmr of property who W)IG or improves thereon•and
who cenhacufar such projects with a contractor(s)licensed punusnt to the Comemoh 202 - UNDERFLOOR PLUMBING
License law.
0 lamaemptunders. ,B&PCfmdd.. 203 - UNDERFLOOR MECHANICAL
OwnerDate 204 - UNDERFLOOR FRAME
WORKERS COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby amain under penalty of perjury am or the following declandans: 301 — ROUGH PLUMBING
wand will maintain aCertificate ofC...t to self-more four WorkeesCompen- 302 - TUB & OR SHOWER
weak f r h W Rrm+Section t is d77W of the labor Cade.fm iM performance of the 303 - ROUGH MECHANICAL
O l haw and will maintain Workers Compensation lmurmee,an required by Sudan 304 - ROUGH ELECTRICAL
370D of the Labor Code,far the performance of the work["which this permit is issued.
305 — FRAME
My Workeri Campensati.Inmrance CA and Policyy?ober am:
Lt�ec.SiAfE FVN� Poll,-# / 4)o-�o Z 306 — HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS 307 - INSULATION
COMPENSATION INSURANCE
(Dissection need nolhecempleed)fthe perenhis fmomhunthed dollars($100) 308 - SHEETROCK
rakes) 309 - EXTERIOR LATH
I artily that in the performance of the work for which this permit is Word,I shall not 310 - INTERIOR LATH
employ any person in my manor an u W become subject to the Worlso Cmnpcosmi
Laws.1caliramk.Dam 311 - SCRATCH COAT
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT.IE after making this Certificate of Exemption,you should
become subject W the workers Compensation provisions of Ne talau Code.you must 501 - FINAL ELECTRICAL ENERGY
OZ foMwthcomply with wchryovitlomorthispe.11ahJlhedecmedrewkc0. 502 - FINAL PLUMBING ENERGY
N
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
'pat r I hereby emam slut then Is.construction lending agency for the Performance of
IL'> the work for which this permit is leaned(Sm 3017.CIv.C.) 504 - FINAL BUILDING ENERGY
Landers�Z Name Lundeen Adelman 505 - FINAL ELECTRICAL
C)O Icealiry 0.11 low read this appllcetiem aM s e dm the aWw information I. 506 — GAS TEST
O correct.1 Rms to comply with all city and county arguments and ante laws relating W 7 _ FINAL PLUMBING
Wildinjcaustruetion,and hereby mthorim representatives,of this city he enter urns the
W above-mentioned property for Inspection Purposes 0 F I L MEC I CAL
(wed almost be on,indemnity and keep historical to City of Committee agalml 9 — FI
W Iubilities,judgments,eon and expemem which may In my way scone,against said City
U 7 In consequence of the Sooting of this penult ING
F7 APPLICANT UNDERSTANDS AND WILL COMPLY W ALL NON-POINT Issued by: 5 8ta
S R REGULATI 4A
3 O 3 Re-roofs
I um of AppliwnUComMor ant
HAZARDOUS MATERIALS DISCLOSU0. Type of Roof
Will the applicant or forum Wilding occupant sem mhend)e hazardous maerisi
as defined by the Consortium,Municipal Code.Chapter 9.12.will the Hedth and Safety
Code.Sued.25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Dy" ),rNo
PWill the applimntorffuu'ro`re buildingocoupatttuseequipmentatdevicas Willett a roof is installed without first obtaining an inspection,I agree to remove
vaadnm air comemiunu u domed by the Bay Ams Air Quality Management all new materials for inspection.
nrict7
Dyes )00
I hewreW the bawdmsm.teri.hmquimm res underCMptor6.95 ofthe Calder.
nisHcelth&Saimy Code,Sactiom25505.25533 md25531.1 m dem.d thati(the Wilding
dams m,.mamfly hew•tm.nL eJ It is as mryomiNli,Y edify the aueupanl the
named nu khmunMmc W hCCNf ofOcco Signature of Applicant Date
� 3 All roof coverings to be Class"B"or better
Owner or authorizad agent Dam