08090152 CITY OF CUPERTINO '77
BUILDING DIVISION PERMIT i�CONTRAGTOR INEO]NATION ;-
.�`,:>
BUI I G FSS: " PERMIT NO.
�wglr RODRIGUES AVE CUPERTINO KITCHEN DESIGNS 08090152
cR'S NAME: PERK IT ISSUE DATE
PHILIP & AMY BLOCHER 10562 . 5 DE ANZA BLVD 09/23/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 257-4900
ARCHRECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 o p LICENSED CONTRACTOR'S DECLARATION
M
I hereby affirm Wt I am licemed under pmvizwm of Chapter Y(commencing lob Description
with SectiontOflU)ofDiviaion 3afWBminmanditfa.m Code,amdmyaccnxis KTCHN RMDL (144SQ) , MINR STRUCTRLp
n m in full fwoe end effect to$U h 63
iq? Iuenre clue Lk.g ELCTRC/PLMB/MECH-NO ROOF
��, Dam _mtetr Kf•uPr� run fwy��rf
£ ARCHr1ECTs DECLARATION qq IN
u I understand my plain ahtll W used u public records 1ki,J
JyUr '
yC 3
Licensed Pmfeuian.l
OWNER-BUILDER DECLARATION
E<F 1 hereby maso .limn Wt 11. exempt from the Conmcmh License Law for the
E.0 follwhich
moon.Permit
t 703 construct.
Business and Pm,dem m Code:Any city s county
which its issm n permit to arra..alcor,i t for such
demolish, fi mpoir anis smctum
9 i y prim b its i eased pursuant
rtgoiOn W.pions o for such permit m m.signed rommcnt
< Nathe islicensedwit pumtanuoW of Division
of the Contractor's�esand (Chapter 9 odc)or Sq.Ft.Floor Area Valuation
z�$ (commencing with Spoon 7000)afDivuion Sof the Business and Profcaiom Cade)ar $60000
Nat be is exempt therefrom and the buds for W alleged exemption.Any violation of
Schon 7031.5 by a"applicator fora permit subjects the applicanuo anvil penalty ofNumber Occu
ucl owe Nae five hundred dollars ISM 36904043 Pane Y Type
❑1.u owner of W papery,w my wPloyw wins wgex u W'vsom compensstion,
will do On work,and W smmure is not intended woRered for sale(So..7W,Business
and Professions Gndc:Than ComKmr's License Law does not apply to an owner of Required Inspections
property who WLldswimpoveslhvwn,and who daessuch work himself or through his
own employees,provided that such improvements am nw intended oro@rtd(mule.It
hownver,Ne Wilding or improvement is sold within one year of completion,Ne owunr-
Wilder will have W Wrden of proving that he did wt Wild or improve for purpose of
ole.).
❑1.as..of W properly.am exclusively contracting with accrued contractors to
summa W pmjm(sec.ma,Boom.and Profeumns coon:)The Comiractors u-
cense liw docs not apply to an caul of property who Wilds or impmvm direct.and.
who contacts for such ioxio.with a contracmr(.)licensed pursuant to W CmuractoYs
License law.
amexmytunderSee ,Bk Pcfunthisreason
Date
WORKERS COMPENSATION DECLARATION
I hereby afrum under Mostly of perjury one of W following decla mom:
❑Ihaw.nd will maintains Certiapx ofGmxmmxlf-insurtfunWOM1elsCompp-
satim.as provided for by section 37M of Ne Labor Code.for W performance of the
wort for which this permit Ls Wood.
1 have and will maintain Worker's Compensation Irtuuvip,u inquired by&&tion
37000 On Uwe Code.for the performance ofdte work fwwhich this permit is hound, '
My We lace,Compewtion lltsmaep p�ricy and Policy number ace,
carier.5-61a- C,.wv2.rsG, licyNu:rnanti)o-20oA
CERTLFl OFEXEMPDONFROMWORKERS'
COMPENSATION INSURANCE
(Thlzxedm acted tar be connpietnd aft permit is fwone hundred doBaa(5100) > .
or less.)
1 ratify met in W performance of W work For which this Permit is issued,L shall not
employ any person in any mannerso as to become subject m the Workers Compnts don
Laws of Califomit Date
Applicant
NOTICE TO APPUCANP.If.alcor making this Certifpm of Eumption,you should
become subject to On Workels Compensation provisions of the Lftr Cede,you meet
z forthwith comply with such provisions or this pennil shall he dpmed meted.
?O CONSrRUCnON LENDING AGENCY
[—r la
1 hereby arm Nat Wu rsetert a co1m.kruding.lime,for On perf..of
E W work for which this Permit is iniad(Sec.3091,Civ,C.)
0. Q Lcndefs Name
z lenders Address
V Q I comay,that 1 have read this application and sate this W shove imiconotion u
LL correct.I agree to comply with all city and county om mNRt and state laws relating to
Wilding construction,and hereby authorim mpmmnudves of this city to enter upon the
.hove-memtionee property for itupeaion purposes.
F W (We)agree to save,indemnify and keep hamlets the City of Cupertino against
fn liabilities,judgments,row and expenses which may in any'w'ay semue agaimt raid City
t.)Z in consequence of the granting of this perm,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU /C..i� li!7
R REGULA ONS.
G � Re-roofs
RA
signaturesignatureofAppl¢aar Dam
HA2:ARDOUS MATERIALSDISCLOSURE Type of Roof
Willy Me Cupertinont Or turciisal Cong e.Chapter
mm handle Health mmamrial
Medio tit Cupertino Municipal Code.CWpmr 9.13,and the Fkalth and Safety
:. El Y.
All roofs shall be inspected prior to any roofing material being installed.
❑Yes tB�e
If a roof is installed without first obtainingan inspection,I agree to remove
Will Wii, emarinfuture Wilding by ft Bay
.Air Quality
M...which P
emit dans air cucuminsnu u leaned by W Bay Ama Air Quality Management all new materials for inspection.
❑Yes [?NO
I have mal the haaNeas materials requirements under Chapmn495 of W Califor-
otHcal"SafetyCoo.Sections25505.25533 and 25574.l understand thmifNc Wilding
dos root currently ban a terms.Out resi
it it my responsibility m entry do mvpant of We
mag Lm uwhich muse W met In W5 roof.ccm�rmp,of Occupancy. Signature of Applicant Date
ty
Owner or mlhomcd agent Dam All roof coverings to be Class'A!'or better
'