03070046 C OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INT'O$ IATION
BUILDING ADDRESS: PERMIT N003O70046
OWNER'S NAME: PERM T ISSUE DATE
NE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
J00 LICENSED CONTRACTOR'S DECLARATION
mF 1 hereby affirm that 1 am licensed under provision¢of Chapter 9(commencing Job Description
�Zwith Section 7000)of Division 3 of NC Business and Professions Code,and my license is - — w,w ff CC
n<n mnmrecand errem. ADD 171 SQ. FT. /KITCHEN REMODEL F'I�/� LEO
j ? License Class Llc.If
e F Ow Dow Contractor
ppwyW
ARCHITECT'S DECLARATION MAR 1 5 2004
�2a I nda,,mbd my plans shall he used as public records
5yU
e0F Licensed Professional
3 OWNER-BUILDER DECLARATION BUILDING
'yL a P I herehy affirm that 1 ore exempt from the Cnnuacmr'a License Law fm the
CCICfollowing reason,(Section 7WI.5,Business and professions Code:Any city or county
which requires a permit in construct,alter,improve,demolish,or repairanystructure rono
poor III its issuance,also requires the applicant for such permit to file a signed statement
E£xx< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
yFrs (commencing with Section 7")of Division 3 of the Business and Professions Code)or
y Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of 32649024 . 00
Section 7031.5 by any applicant for a permit subjects the epplicanuo a civil penalty of AIN Number Occupancy Type
not mom than five hundred dollars($500).
❑1.as owner of the property,or my employees with wages at Weir sole compensation,
will do the work,and theswcwm is not intended or offered for sale(See.7044,Business iul — ITJ"Ad Inspections
and Professions Cade:The Contractors License Law does not apply to an owner of 10 2 - PIERS
property who builds or improves themes,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for ale.If, 103 — UFER
however,the building or improvement is sold within one year of completion.Ne owned
builder til have the burden of pmving that he did not Wild or improve for purpose of 104 _ REBAR
s1e' 105 ANCHOR BOLTS
1.a¢ownerof the pm,strtam,, ely Protracting with:)Theeticonvactoss to 106 - SEWER & WATER
construct the project(Sec.]044,Business end Professions Code:)The Contractor's Li
cense law does not apply w an owner of property who builds or improve¢Nereon,and 202 - UNDERFLOOR PLUMBING
who contracts far such projects with a emarantar(s)licensed pursuant to the Contrselm's
License Law. 203 - UNDERFLOOR MECHANICAL
0 lam exempt undo c. B At P C for this reason 204 - UNDERFLOOR FRAME
owner Date 205 - UNDERFLOOR INSULATION
WO ER's M E SAT NDECLARATION
I hereby afruspu der penally of perjury one of the following declarations: 3O1 — ROUGH PLUMBING
I
lo',:o .n'dwillm ina Cenificme of Consent to wlf-insure for worker's Camper- 302 — TUB & OR SHOWER
¢abort,as provided for by Section 3700 of the Labor Code,for the performance of the 3 03 - ROUGH MECHANICAL
work for which this Permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as requited by Section 3 04 - ROUGH ELECTRICAL
3700 of the labor Code for the performance of the work for which this permit is issued. 305 — FRAME
My Workers Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Cartier. Policy No.:
CERTIFICATE OFEXEMMON FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not k completed if the permit is far one hundred dollars($I U)) 309 - EXTERIOR LATH
or Icsa,)
1 certify that in the perfaumanco of the work for which ibis Permit H Issued,I shall not 3 10 — INTERIOR LATH
employ any person in any manner so as in become subject o the Workeri Compcn¢ation - 311 — SCRATCH COAT
Laws of California.Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Com petuation provisions of the Labor Code,you most
J Z forthwith comply with such provisions In this permitshall he decried resulted, 502 — FINAL PLUMBING ENERGY
z O CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
IherehyIdEn.thatthemisacmutoelianlemdingagencyiorahePerformanceof 504 - FINAL BUILDING ENERGY
Cli 7 the.,it for which this permit is issued(Sec.3097,Co,C.)
W A Isndcra Name 505 - FINAL ELECTRICAL
� z
Lon 506 - GAS TEST
U O I certify Nm I have reed Nis application and sate that the shout information is 507 - FINAL PLUMBING
correct.I agree to comply with all city and county ordinances and state laws relating to
C) U building construction.and hereby authorim nipmarboadvaI,of this city to enter upon the FIN MEC I- CAL
ahovcmentiened pmKrty for inspection purposes.
(We)agree to save.indemnify and keep harmless Ne City of Cupertimo against O 9 FIN
N
i N
liabilities,judgments,costs and expenses which may in any way same against said City 5 NWG
in
U APPLICANT eUNDERSTANDS of the ninon,of tAsp=WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date
SOURCERE ATIO s
Re-roofs .7 `O
Si news of Ap en✓ omr czar Date (—
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF f
Will the Cupar smor future building e,Chant r9.12,re and the
hnartous material
az defined by the Cupertino Municipal Code,Chapter 9.11,end the Nca1N and Safety
CoJc,Scction25531(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
win the applicant o future building occupant use equipment or devices whish If a roof is installed without first obtaining an inspection,I agree to remove
I
havardous air conmminanu as dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
shave wad thehmsrdn mawrials reyuiremcnu under Chap¢r6.95 of Ne Califory
ria Health&Safety Coda Secdona255115,25533and25534.landersrend Nwifthe Wilding
does not ee mu ly haw a tartans Nat it is my responchility to naul'y the occupant of Ne
requirementsichmust mit ti Iafsscanceor.Cc¢ficatoofOccapamcy. Signature of Applicant Date
erntanNa vedasent Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
BUILDING DIVISION PERMIT • CONTRACTORaINFORIMATI
BUILDING ADDRESS: PERMIT NO03070046 3070046
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL N0.
ARCIi1TECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH l
100 LICENSED CONTRACTOR'SDECLARATION Job Description
4 Vm affirm that I am licensed under provisions of Chapter 9(commencing
nU with Section 70(0)of Division Softhc Busincssand Professions Code.and mylicensc is
1.ferce License Class d effect. Lie.# ADD 171 SQ. FT . /KITCHEN REMODEL
e Date Contract.,
ARCHITECTS DECLARATION
1 understand my plane shall he used as public records /J(L/
! � L
=o In Licensed Professional W,
3 OWNER-BUILDER mDECLARATION
COO I naso affirm that I ore exempt from the Contractor's C License Law for the /
O O which re reason.(Section]1131.5,Business and ve demolish,
Code:Any city or counre
5$ which requires issuance.pmmit enthe alter,nt rrow,do ermit t rte a poi, ed ummerc
hit he i¢ ensedore requires,tohe the applicant for such ConrcrmrUnrlcse,Law naemem
< that heislimnuJpuruanUolhepmvisinnsnfthe Contma't.rsLianxl�w(Chaper9 Sq.Ft.Floor Area Valuation
eH (commencing with Section 7W0)ol Division 3.fthc Bminesa.md Pmfessi.n.Code)ser Y
e $ that he is exempt therefrom and Ina basis for the alleged exemption.Any violation of 32649024 . 00
Section?831.5 by any applicantfor a permit subjects Ne applicant to a civil penally of APN Number Occupancy Type
not or.then five hundred della.(5500).
❑I,s owner of the property,.1 my employees with wages ss their sole compensation,
will do the work,and the suichim is not intended or offered for sale(Sec.7044,Business 101 — eTggKd Inspections
and Proassi.m Code:The Contractor's License Law does not apply Or an owner of 10 2 - PIERS
property who builds or improves thereon,and who does such work himself orthrougb his
rvn employees,provided that such improvements are not mended or offered for sale.If. 103 — UFER
however,the haildi all or impmvem=nt is mid within one year of completion.Ne owner.
builder dl have the burden of proving Nat maid not build or imponafor purpose of 104 _ REBAR
•ale' 105 ANCHOR BOLTS
I,as owner of the reopen,am exclusively contracting with licensed contractors to 106 — SEWER & WATER
consumer the project(Sec.7044,Business and Professions Code:)The Contractors Li
cense Law doesnot apply to an owner of progeny who Wilds or improves thereon,and 202 — UNDERFLOOR PLUMBING
who Comracufor such projects with a com.ctor(s)licensed pursue ml to the Contractors
Lkense Law, 203 — UNDERFLOOR MECHANICAL
0 Onexempt.nx _.a&PC for this...n 204 — UNDERFLOOR FRAME
owne, Date 205 — UNDERFLOOR INSULATION
WO (ER's M ENSATI NDECLARATION
I hereby 7)it of perjury one of the following declarations: 301 — ROUGH PLUMBING
l mwandwiii an0 in aCemre.te of Consent m sel&iaeere for workers Com,en. 302 - TUB & OR SHOWER
cation,.povided to,by Section 370 of the Labor Code,for the poff......f the 3 03 — ROUGH MECHANICAL
work for which this permit is issued.
I have and will maintain Worker's Compensation Tnsu.nce,as Ieyvited by Sermon 3 04 — ROUGH ELECTRICAL
3700 of Ne Labor Code.for Ne performance of the work for which Nis permit is issued. 305 — FRAME
My Worker's Compensation Insurance carrier and Policy number are: 306 — HOLDOWN6
Cartier. Policy No.: _
CERTIFICATE OF E%EM MON MOM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
(This section need not he compmedHite permit is Tor one hundred doll,.tila0 309 - EXTERIOR LATH
or lcsx)
I certify that in the performance of the work for which this permit Is Issued.I shall nut 310 — INTERIOR LATH
employ any Person in any manner so as it)become subject to the Workesi Compensation 311 o SCRATCH COAT
Laws of California.Da
Applicant le 313 — ROOF NAIL
Laws
NOTICE TO APPLICANT:If.after making this Confiscate of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subjeet to the Wo,kce's C.mr nsta on provisions of Ne Labor Code,you must
.JZ forthwith comply with such provisions or this permit shall be deemed revekcd. 502 — FINAL PLUMBING ENERGY
zoCONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
t,..t tNr (hcrchy affirm that Nero is a construction lending agency fur the Performance.( 504 — FINAL BUILDING ENERGY
LYi the work fur which this mit peris issued(Sec.3(197,Civ,C.)
W q Lanai Name 505 — FINAL ELECTRICAL
z LendersAddtess 506 — GAS TEST
U O 1 certify Nat l have mad this application and sue that she.how information is 507 — FINAL PLUMBING
correct.I agree to comply with all city and county ordinances and state laws relating to
p U buildingconawcuon,andherebyauthorim«prosentadwsofhiscitytoeneruponthe FIN MECjtNG AL
W ah.vomentioned progeny for inspection purposes.
y (We)agree to saw,indemnify and keep harmless the City of Cupertino against 0 9 FIN
.y rq Iiahilitics,judgmenLxcosts and cx,emaswhich may inany way accmcagainst said City 5 U Z In consequence of the grab ng of this permil.APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by:5 ORKS Date
SOURCERE ATIO S/
Re-roofs ''TT77
S nature of App i ant/ ontr ctor Data fV\ /.._ ._
HAZARDOUS MATERIALS DISCLOSURE Type of Roof �, C
Will the' pliant or future building Occupant store or handle hxemdous material (((
as defined by the Cupertino Municipal Calc,Chapter 9.12.and the Health and Safety
Calc,Section 25532(.)7All roofs shall be inspected prior to any roofing material being installed.
O Yes
Will the applicant. mtur building Occupant ase equipment Or devices which .If a roof is installed without first obtaining an inspection,I agree to remove
mit baMous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
DLtrlC17
❑Yes N'
maNn ma
I have read the hteriab reyuiremcntsunder Chapter 6.95 ofthc Califon
nixHealth&Safny Code,Semens 255115,25533 and 25534.1 unescomnd the iftM Wilding
does not en mently how a motion,that it is my feerkosibility to notify the occupant of the
myviremcnu fonm..t Uma nytaniMuanee.r.CeniEeae.faeupancy. Signature of Applicant Date
cr or aaho red agcm t Date All roof coverings to be Class "B" or better