05090228 CITY OF CUPERTINO -�-- "' "
BUILDING DIVISION PERMIT CO NTRAC,Tt)RNFOR, MATIO.N
BUILDING ADDRESS: KITCHENS BY MEYER PERMIT No.05090228
176 RAF, T-N
OWNER'S NAME: PERMIT LSSUE DATE
IPMARY & ACLE HICKS 278 5
E SANITARY NO. CONTROL NO.
(415) 968-8318
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EfECf PLUMB MECH
u o o LICENSED CONTRACTOR'S DECLARATION
lwF1 hereby firm that 1 em licensed under provisions of Chapter 9(commencing Job Description
SZaffirm
ty with section Oiviaion Sof the Business and Profession,Cods.end my he..is
-_„ in lull fm�andrD((D((((aaaaaaaaNNNNL �-� 7 J KITCHEN REMODEL/CABINETS COUNTER
3z Liceee nLle.N r
p
-o Dam Conv���r ga_pQt�Lta— UPGRAE ELECT. /SHEET ROCK
�� ARCHITECTS DECLARA ON ®®
UI usbcrstand my plans shall he need as public retards E
aQ� Licensed Pmfessional
5 OWNER-BUILDER DECLARATION FINAL
s<x I hereby atinm that I am m empt from the Contractors License law for the
ZOO following moon.(Section 7031.5.Business and Professions Codi Any city or canary ��� 2U�8
$ which requires a permit m constrwa,alter.improve,demolish,at repair any structure
prior to its issuance.also requiwa the applicant forsuch Permit o rile a signed statement ,,[[aa
< Nat he is licensed pursomt to the provisions of the Co micmrs License law(Chapter 9 Sq. Ft. Floor Area 415,500
z�a (eommeneingwith Section?OBB)of Division Sof NC Businecsand Profiessioni in
that he is eaempt therefrom and de basis for the alleged oarnpiian.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Numbera nC T
nota mManfinhundreddollars(ssoo). 35607048 . 00 y Y�
C]I.aownaofthepmNay,ormyemplowawithwagesmftirwlccompenution,
will do thewast,endthes umum 4 notinmMedoroReed fmule(Sec.7(l55.Business
and Professions Code:The Conuxtors License taw does not apply m in ower or Required Inspections
propenywho builds orimprowa dhercon,and whodoes smhwark himself or through his -
own employees,provided that such Improvements are not intended proffered hassle.If,
however,Ne building or improvemem is sold within ane year of oompletion,Ne owner.
builder will)taw the burden of proving that he did not Wild or improve for purpose of
vid')
❑1.as owner of the propcn,am exclusively cmtrscting with licensed cantmend.m
contract the project(Sec.7054,Business and Professions Cade:)The Combacmr's u.
cense law docs not apply to an owner of property who builds or improma Memon,and
who contracts for such projects with a eontractur(s)licensed pursuant to the Convectors
Licmtse law.
❑1 am exempt under Sec. .B&P C for this reuon
I
r - Data
WORKERS COMPENSATIONDECLARATION
ffiI hereby arm under penalty of perjury on,of the following declarations:
ftnnseNw and will maintain a Cenite of Cont w self-iaure fm Wmkces Campemn,as provided for by Section 37W of the labor Code,far the perannu me of Ne
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as rcquircd by Section
3700 of the LaMar Code.for Me,performance of the work for whim this permit is issued.
My Workers Compensation Insurance artier and Policy number am:
Came'A'Cof!sS PolicyNo.:)�91y_fL-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ihismcdm mutant becomplemd if the permit is formic hundred dollars(SIM)
or leu.)
I certify that in the performance of Ne work for which this Permit is issued.1 shall not
employ any person in any mancerm in m become subject to Om Workcia Compewtion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifcam of Exemption,you should
become subject to Ne Workers Compensation provisions of Ne labor Cade you am
.,z forthwith comply with such provision,or this permit shall be dcemeg revoked.
zO CONSTRUCTION LENDING AGENCY
[-� Thereby elifm that then is a construction lending agcmy liar the,performance of
C' the work for which this permit is issued(Sec.3(X97,Civ,C.)
Q Lenders Name
D z Lender's Address
U O 1 sandy that 1 haw rad this application and stat that the flow information 6
!rs Fcorrect.1 agree tocomply with all city and county ordinances and state laws relating to
C) U building convection,and hereby audrourz representatives of this city to order upon the
shove-mcnuomg property far inspection which may
F a (We)agree to sew,indemnify and keep harmless Ne City of Cupcnino against
rA Uzin coisequenoofth,craning Of this ataft.may in any way accrvc against said City
n coaegmmc of the Granting of this pesmid.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of ApphcanVConData c Re-roofs US MATERIALS DISCLOSURE Type of Roof
Will Neapplicant of frame ipal a Occupant.Chptr ore 9.12.handle Holds and
as m.Sea Section
the Cupertino Municipal Data.Chapter 9.11.and the HcaIN and Sa(ety
crx.suction ss532(a)? All roofs shall be inspected nor to an roofing material beim
C-]yes p5ou— P P � Y g g installed.
Will the apptiant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air cmtammants as thfimd by the Bay Area Air Quality Management all new materials for inspection.
DiWict? — /
YC9 �1V0
I hawread the Wv wsmacrialsmquimmentsunder Chaper6.95oftheCalifor-
niaHalth&Safety Cogs SectiousnM5,25533end25534.lundenamadthatifthc Wilding
data not currently haw a mnastt.that it is my responsihitity m madly the meopent of the
reggi� cats hm tn,t pan r eracen;feamrrompamy. Signature of Applicant Date
own a mratnmdlodagem Dam All roof coverings to be Class "B" or better