04110016 CITY OF CUPERTINO vsa;prs+?x
BUILDING DIVISION PERMIT �,CON'TIUCTLIR,�INP -AMA.V.ON,,�;",,,
BUILDING ADDRESS: PERMIT NOQ 4 110 016
10158
OWNER'S NAME: PERMIT L'SUE DATH
GRANT & ELIZABETH GOWER
SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUIWING PERMIT INFO
BLDG ELECT PLUMB MECH
] 0 0 0 0
aIOO LICENSED CONTRACTOR'S DECLARATION Job Description
tin 1 bacby.M.the I are licensed tact p visions of Chapin 9 mommeucinj
with lion] )of DiAionlof:a ProfeWons Code.andmylicnsmis
inrauta eif k REMODEL ELECT. /KITCHEN/BATHRM
Damn kv ARCH nECI'SDbl.a ri s' CONTRACTOR: W.G. FRITZ CONSTRUCTION
ntletmend my phns,lull be eased u p
U
c Licensed Professional
OWNER-BUILDER DECLARATION
K a I I heroby aRirm that 1 1. exempt(mm the ConwutCo :Any c Law for the
my
O O following mason.(Sagan 7th sir Busmen and ere.de ens Code:Arts city structure
Ka 9 which requires;n permit re conswn,alms improve,demolish,m mpotr ed awnent C
�y,+ that Wprior )i u lensed Pce,also..nL toims the
ovisio sof for sub Cort permit m file a terum signed sommcm
e momonermcgwithSmile.toNepmvisioime3ofteBut r'sLIcemelsw(Chaptm9 Sq.Ft. Floor Area VaIU$Ca}�gQQQ
zCO (ea he is turps Sccuane and the
basis nlnfmocBWwsand PmfAn vi Code)or
3 S Nu he b eumpt Ine¢fmm and the Weis for do ulegW wmptlon.Any Halation of '
section 7071.3 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mare Nm five hundred dollars($500}
❑1.nn of0apmpeny.mmyemploycuwithwgesuthe mit mpemWrm, 34241011 . 00
willdomotwork,aod Neswcture Is rommusdedm ofters for Wc(Sec.7044,Busireu Required Inspections
and Professions Code:The Conu¢tor'a License Law Eon nm e ns apply to an owner of q P
property who build,or i mpmvn thereon,and who does auch work himself or tluough his
awn employee,provided that such Imptovrmanuaro not intended mo@seA for We If.
however.the Wilding or improvement is sold within one year ofcomp]etion,the o'w'ner.
builder wig lave the Emden of proving that he did nm build or improve for purpose of
sole.).
❑1.an owner of the property,am exclusively contracting with licensed convenors to
coca met the project(Sec.7014,Business and Professions Code:)The ConvumA Lt.
cense Law does not apply to an owner of property who builds or improm moment,and,
who convects for such projects with a contractor(s)licensed pursuant to the Conuaetoes
License Law.
❑I am exempt under See ,B&P C for Nin moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaratiana:
737:00
have end will mainuin a Certificate of Consent mself-imum for WorkelsCompen-
n,u provided for by Section 3700 of moa Labor Code.for W Performance of mot
for which this Permit is inocd.
haw;and will maintain Worleces Compensation harmomm,n required by Section
of Isbor Cade,far the performance of the wart forwIt hmots permit h issued.
a ea Compemadon In m canterandPolicy nu.Mare:Policy Nen �aulea��
CERTIFlCA F E%EMPI70t1 F$ M WORKERS'
COMPENSATION( RANCE'
(This section need net N completed if the .It Is form.hundmddollan(SIM)
or less)
I certify that in the performance of the work for which this permit is issued,10.11 not
employ any person in any manner se a e become mbjat to moa Workeri Compensation -
Laws of California.Dam
Appllcam
NOTICE TO APPLICANT:If,after making this Certificate of Eaemption,you should
mature subject in the Worker's Compeundon provisions of the Labor Codc,you mum
O foMwic,comply with such provisions m thinµnit shot]M dcemed mmked.
�,i'^' CONSTRUCTION LENDING AGENCY
,e-1N I hereby affirm Nat them is a construction lending agency rat dm Performance of
CYi 7 the wort for which this Permit In iuned(Sec.709],Civ.C.) _
W Q Lundeen Namc
rti. z Lender'sAddress
U0 1 certify that I have mad this city
and coup and sate Nn Ne above w minuet 1.M
0!'t coweL 1 gree mi amply with all city and teems ntatnaatta and exam Wawa rtlNn{m
Q LSU+ Wilding construction,and hemnY aumoon PUTWcsenudve,of this city menles upon mot
W shove-mee)nu I-ertynow.(m imnifyapurcpW
v] o.
(We)agree m cove,indemnify end kap harmleco the City of Cuµnino again
fq inconsesenceo th,costo and expenaamit. may in any wyaccme against aid City
C)z Aconsequence ofDRSTANDSthis pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OURCE REGULATIONS.
'-'-
f App , >Z•ls�au_ Re-roofs
ftranvConuenor D te
HAZARDOUS MA RIALS DISCL63 E Type of Roof
Wioll the applicant at future Wilding occupant more or handle haysmaus maredm
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section35773(.)? All roofs shall be inspected prior to any roofing material being installed.
❑
11 the applicant or furore building occupant use equipment or dcvlas which"PoWiIf a roof is installed without first obtaining an inspection,I agree to remove
Il Immodour air contaminants as deMcd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yrs cI
I have soul the tursmtmn o M%5, re 33 and 55 under Chapter Q95o(the Wilding
not Health&SotetyCode,Secthans 33505,37577 and 35534.1 undersand moo if the Wilding
ocs not currently hors a u n m,Nu it h my responsibility a notify the occupant of Ne
minus, whichmetpnor anceofac=rlwamafoccTfwy. Signature of Applicant Date
Osumi uthadaedagant \\\..�/���iggll``Dam�� All roof coverings to be Class"B" or better