03110086 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT > CONTRXtCT,nR INFORIVTATION3
Bu EDING ADDRESS: SHOWCASE KITCHENS INC PERMIT N003110086
21578 ROSARIO AV
^� NER'S NAME: PERMIT ISSUE DATE '
RSHALL WILLIAM J AND ELIZAB 12333 SARAT G - 11/17/2003
NE: SANITARY NO. CONTROL NO.
(408) 253-0412
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION
C I hereby affirm in I am I recd under pro axions of Chapter 9(commencing .IOb Description
U with Sect�io�n a]nOBIB of Division Sof NC Businexaa ofcssions Code.and.1 license is
�t«�Is�rr�lxaerraEn LigV7 VrZl:�
RELACE SHOWER TILE
it-w Dale Cuntractor
pp ARCHITECTS to,
E C -
d 1 undcrsund my plans shall he used as public records
>yU
rLL y Professional
3 OWNER-BUILDER DECLARATION
2<q 1 hereby afford that 1 am exempt from to Cmdraaors Licca.Law for the
pO following mason.(Section 7031.5.Business and Professions Code:Any city or county
3=� which mquires a permit to consumer,alma improve,demolish,or repair any struchoc $2300
or prior to its issuance.also requires the applicant for such permit o file a signed aammcnt
gs� that he is licensed pursuant o the pmvisions of the Contractors License lsw(Chapter 9 Sq. Ft. Floor Area Valuation
2x-$ (commencing with Section]000)of Division 3 of the Business unit Professions Cade)or
y .. dint he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects to applicant o a civil penally of or00 Occupancy Type
nntmoredianfivehundred dollar.D500). P Y YP
❑1,as owner of the properly,or my employees with wages as their sole compensation,
will do the work,and the shi clure is not intended or offered for sale(Sec.7M4,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
awn employees,provided that such improvements ere not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving Nal he did not Wild or improve for purpose of
sake.).
❑ h as owner of the property,am exclusively contracting wit licensed contractors to -
construct the project(Sec.7044,Business and Professions Cutler)The ContrecmrS rad
cense law dors not apply a an owner of property who sed p or improves thereon.and
whocontractsLaca for such projects with a eonvanor(p licensed pursuant to to Convectors
License Law. /
❑1 am exempt under Sea B&P C(n this rcsson
•minerAQ KE��Q�Dam j
WORKER'S COMPENSATION DECLARATION Q
I hereby affum under penalty of perjury one of to following emanations:
J l have and will maintain a Cenifcam of Consent to self-insure for Worker's Compen.
amkon,as provided for by Section 3700 of die labor Code,for the performance of the
work for which this permit is iscoed.
C3
1 have and will maintain Worker's Compensation Insurance,as required by Section
",of to labor Codc,for to performance cite work for whieh this permit is issued.
My Worker'sCompensation Insuanm carrier and Policy number am:
Card ra}��/ ��b \Pol'w No,:
CERTIFICATE OF EXEM FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($HXB
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so an to become subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should
become Subject to the Worker's Compensation provisions of the tabor Code,you must
.,z fortbwi in comply with such provisions or this peanut shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a censuaction lending agency lot the performance of
'Ya die work fur which this permit is issued(Sic.3097,Ci,C.)
W Q Under a Name
Lender's Address
D
U O 1 certify that 1 have mad this application and sant that the shove information is
W P corteet.l agree to comply with all city and county ordinances and ram Iowa relating to
0U building construction,said hereby oubmim represenarives of this city to enter upon the
Wabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rHi h liabilities,judgments,Casa and expenses which may in any way theme against said City
U z„ APPeof the romi n,of I
LICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E REGULATIONS.
11l/-710�? Re-roofs
r7c or ApphcanUCommctoo�/a DOdorg
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuwre building Occupant store or handle Wom mus material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑Yesa P P Y g g installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit havamotis air coalition, fined by the Bay Arca Air Quality Management all new materials for inspection.
District?
[I Yes Nu(ref'/
I have mad the ha sidous materials requirements under Chapter 6.95 of to Califory
nia Health&Safety Code,Secuons 25505,35533 and 25534.1 understand dia if the building
docs not currently have a wront,that it is my respoosihility to nod ly the Occupant of the
mq he enrewhich flaxteemeI rtoloatheor Cimreaanfaia ey. Signature of Applicant Date
?�
p anmorized agent a All roof coverings to be Class"B"or better