04010141Yp0
eD t93o
rte!
I-
�U
LLL
03
�CO
i,Zt
D
5$
0z
,z 0
y
>_
MQ
oz
UO_
OU
U
Fy
�z
OF CUPERTINO
BUILDING DIVISION PERMIT
,CCONTRACT,RINFORMATIQN
FCITY
LDING ADDRESS:
4j c) qTAmT?nRT) PT
CUPERTINO KITCHEN DESIGNS
PERMIT Ncb4010141
ERS NAME:
FERMITISSUEDATE -
PHONE:
SANITARY CONTROL N0.
N0.
ARCHITECfIENGINCER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I�
LICENSED CONTRACTOR'S DECLARATION
Job Descrl tion CC
Ir
I W by of rut that I em licensed under prowhoons of Chapter 9 (commencing
P
With Sectio fOivioonSofNCBu,ircuwp Prof.,*.. Code. snd my license Is
in full mmea erre i�J 63
Littnse Class r Lic.
KITCHEN REMODEL MAY 11 2004
'
Da¢ Co uazt
\' ' ARC I'I -1 S ION
I Abp tend W Ile
my plana shall rad a, records
BUILDING
Licensed Pmfessiunal
OWNER -BUILDER DECLARATION
1 berehy affirm that 1 am txcmpt from Be Contractors License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
Which requires a introit 10 matrecl, eller, imprnw, demolish, at repair any structure
Prior m its Madame, also requires the applicant for such pcont,to file a signed statement
that he is licensed pursuant to the provisions of the Contmesm's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cork) or
that he is exempt therefrom and IN basis for the alleged exemption. Any violation of
Smile. 7031.5 by any applicant for a Permit subjects Ne applicant to a civil penalty of
3S Ih95et00
--dc-cue ane T e
P y
not more than five hundred dollen ($50)).
YP
1, as owner of Ne propcny, or my employees with wagesa Ibeir sole compensation.
will do the wart. and the sweture is not intended or offend furmle(See 700 ,Business
and Professions Code: The Comencu is License Law does not apply to an owner of
Required Inspections
property who builds of improves thereon, and who doeaauch work himself or through his
own employees, provided Ihm such impmwmenu ....I intended m offered for saleit,
however. the building or Improvement Is sold within one yev of mo pledim, the owner -
builder will have the burden or proving Nal NO did not Wild or improve for purpose of
sale.).
-
I, as owmr of the propeny, and exclusively contracting with licensed contractors to
eoawcl the project (Sec. rwa, Business and professions Code:) M Contractors Li-
-
mase law docs not apply to an owner of properly who Wilds or improves thereon, and
'
who mmomIS for such projects with a eonlrseer(s) licensed pursuant o the Contractor's
License law.
❑ 1 am eampt under, Sec. . B & P C for this reason
er Dale
WORKERS COMPENSATION DECLARATION
1 hereby eRtm under peaky of perjury one o(Ihe following dmlualioa:
❑ I haw and will maintain a Cenifieam of Consent to self-Insumfor WorkcesCom,en-
aa0on, a Provided for by Seetion 3700 of the Labor Code, for On performance of the
.,it for which this permit la issued.
1 have and will maintain Workers Compensation Insurance, as requited by Section
37W of the Labor Code. for Ne Performance or the work for which this Permit is issued.
My Workers Compensation launnce c d Policy number are:
'
Ca ser. Paliry No.:
E IFICA OFEXEMPTONFROM WORKERS'
COMPENSATION INSURANCE
(7h4xctim raced not be completed if the permil b format hundred dnllats (5If))
lest)
1 certify that in Ne performance of the wok for which Nis permil Is issued. I shell not
employ any penton in my manmsn as to become subject o the Workers Compenation
LawaafCarramia. Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to Oc Worker's Comperuation Pmvisloa of the IamrCode, you maul
-
fenhwith comply with such provision .,,his peroo,sh.11 be deemed revoked.
.
CONSTRUCTION LENDING AGENCY
I Wmby arnfm that Ncre is a eon5Wctim lending agency far IN Performance of
IN work for which this permit Is issued (Sm. 5091, Civ. C.)
Lenders Nuae
Lender's Address
1 mostly Nu 1 have rad our application snd mote that the above m1mmaliun is
correct. 1 agree 10 comply with all city and county mo inroms and rule laws relating to
building construction, and hereby authome representatives of this city to enter upon the
ahuvomenudgmned property for penes Purposes.
(we) agree to ave, indemnify and keep harmless the City of Cupertino against
expenses
judgments, ex peaeswitch may in any way eccmc against aid City
•i
in oduce of thegaming of this permit.
A
TV\
APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
URCE REG CATIONS.
Re -roofs
$ firosted pplicmVCantactor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof -
Will the applicant or future building Occupant store or handle havudaus materiel
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
1c, Section 25532()?
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment ordevices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hmardcus air contaminants a defined by the Bay Ara Air Quality Management
all new materials for inspection.
District?
❑Yes s21
1 have read the hasaNrws materials requirements under Chapkr6.95 of IW Califon
nie FkalN& SafclyCodc, Sm6om 25505, 25513 and 25534.1 undersand Net if the Wilding
it. not C fitly have a Imm aNIDI tis Is my reopeour ily b Y
ry IN YPNI or NC
yuirtmc whicmm�uWmel iauanm certinmmo a cy.
SignatureofApplicant Date
!JL `I to
- All roof coverings to be Class "13 " or better
wncr ur authedad sgrol
Da,e