05060067 CITY OF CUPERTINO 77"-,L• x�rd`�u'
BUILDING DIVISION PERMIT CONI2ACTR INF`U.tMATT01;
BUILDING ADDRESS: PERMIT NOo 5060067
4
'R'S NAME: IN PERMIT ISSUE DATA
TIFFANY TAI 0.6/24/2009
PHONE: SANITARY N0. CONTROL NO.
ARCHMECT/ENGINEER: BUILDING PERMIT INFO"
• BLDG ELECT PLUMB MECH
O
3 �d LICENSED CONTRACR7RS DECLARATION 1^ )eSCripL1011- J ��
I hemby affirm that l am licensed under provisions of Chapter 9(commencing JO�.D , h"I ry f J \\
with Section 7000)of Division 3 of den Business and Protowiuw Cade.and my license is
A� in mu fame andaffem. KITCHEN REMODEL
racClss
DamContractor /0
4� ARCHITECT'S DECLARATION
pi I understand my plana shall he used u public=and, s'V
a u Licensed Perfect...1
OWNER-BUILDER DECLARATION )I+jf ,J•(
<� I hereby affirm that I am exempt from alto Conuactor'a License Lew for the
O 0 following recon.(Section IID 1.5,Business and Probowium Cade:Any city or county \✓
$ which requires a permit to erntroct.alter.hmprove,demuluh,w repair my structure
�^ prior to its issuer¢,also requires the applicant for such permit to file a signed statement
-�< Net he is licensed pursuant to the prevision of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt Ruminate and the basis for the alleged exemption.Any violation of
Section 7031.5
mroam than bve h ndrtdlicant far a
($S 0).it subjects tk applicant to a civil penalty of er0 0 Occupancy Type
❑I,as owmro(theproperty,army emplayewwith wagwwtheirsolemmpenwdon,
windamew,L.ndtheawmumisnatmundedorartemdrmaale(Sm.7W.BWntu Required Inspections
and Professions us
Cade:The Concmrs License,Law dew roto owner
t apply an or q P
property who Mid&or improves th mnam,and who dmseuch work himselforthrough his
own employees,provided that such Improvements art notimse ded aro@rod forwle.It.
however.the building or Improvement is mid within am year of wmpleton.the owmr•
builder Will Mw the burden of proving that M did rot build or improve fen purpose of
wk.).
1.as owner of the property,em exclusively contracting with licensed contractors to \
combect the project(Sec.7044,Business and Profession Cade:)The Conuecmr's I.I. 1
on",Isw tow not appl to an owner W party be WIIN or improves thereon,and,
W
ho contracts for JeN vith togs) rased parswnt to the Contractors
Lken Law.
am axe t er c Date PQ fo is mason
R ERS CO S O EC RATION LV' I
I hereby affirm under penalty of perjury am of the following declarations:
❑1 haw and will far b in eCeNBwre of Consent toxelMnsum for erform aCompem
worn.r provided(pe by Swoon 7700 of to labor Code.for to pertarmwme of the
work for which this permit it issued.
❑1 have and will maintain Warker's Compensation Insurance,as required by Section
3700 of the Mbar Code,far the performance of the work far which this permit is issued.
My Workces Compensation Insurance carrier and Policy number tee:
Cartier. Policy No.: .
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section wed nothccampiemd If tis permit Is terms hundred dollam($100)
or lass.
1 ceni(y that In the perf.., of ft*.,,k which t'a Permit il rued,l shall tent
employ any person in I verso aftaMng9phpj_ Wolter CampenwWn
Laws of CalWmi kylf T
Appllc ✓
NO'I7C TO G ,. Exemption,you Amid
bwam t
we
fa omwns+t prov ow of the Ishan Codi you most
.J O forthwith comply with men provisions or this permit dull ba deamcd revoked. '
Z.t CONSTRUCTION LENDING AGENCY
[--� I herebywhich
Rirm that Nem ha Issued(Sac.
agency far the performance of
Ni dm week fur which Ws permit b isswd(Sec.7097,Co.C.)
aQ lenders Name
.1. z l.endere AOdtess
U Q 1 certify that I haw mad this appiiutiw and sum that the above information Is .
Uy correct.I agree to comply with all city arta county ordinances and cute laws muting to
C7 building construction.and hereby anthorim repramantives of this city to enter upon the
LTl shove-mentioned property for inspection purposes.
(We)agree to sow.Indemnify and kap here len ft City of Cupertino against
cn liabilities,Judgments,cuts and expresses which many my amus against said City
U7 in eansegwnce of the of this pe
F7 APPLICANT U
ErgNDB A K CO Y WITH A N -POINT Issued by: Date
` _� ��V,_) �� Gt Re-roofs
1nuum of Applh HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or future building mcupant sae or Iundle hersNous mew"
Bend by to Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
.section M32(4)?
Ym All roofs shall be inspected prior to any roofing material being installed.
�Nu
Will the applicant or(mum building occupant um equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
emit h.m a.. it crmamiweu w de0m0 by til¢Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea ;ffktiiu
I have mad the ens materials uimmenu on
Npter695 afthe Glifor• -
nhHplNa,5 'ons 1350 7 .735 mend thstifthe building
date;�oot currand a tenent,th —Pu Try to notify upant of the
re ImMonte m deme issuance, eCcrtiBcauof ane. Signature of Applicant Date
wnv ar authonrcd agent De
All roof coverings to be Class"B"or better