06070173 CITY OF CUPERTINO PERMIT " CONTRACTOR INFORMATION
BUILDING DIVISION R�
BUILDING ADDRESS: R.J. PEREZ CONSTINCPEaMITNo.06070173
11118 SUTHERLAND AV
OWNER'S NAME: PERMIT L45UE DATE
WE:MINTZ KENNETH A AND LINDA R 10091 BYRNE AVE 07/25/2006
SANITARY NO. CONTROL NO.
(408) 252-2797
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
O p LICENSED CONTRACTOR'S DECLARATION TS Description
m 1 hereby affirm Wt 1 am licenslicensedvisi
under pmons of Chapter 9(comOesCrlP
mencing
lo, with Section 7000)of Division 3 of use Business and Professions Code,and my liceme is
;may In fullfaonand mfec (eS�060 KITCHEN REMODEL NON STRUCTURAL
,120 Date Clay Lle.g
i Contractor
DECLARATION
�drstand my plans shall he used aspublic
anU
G F' Licenced Professional
S OWNER-BUILDER DECLARATION
I 1 hereby mLrro Nm I am ucmpt from Ne CantmmoYa License law for the
,
120 following recon.(Sadun 103 1.5,Business and Professions Code:Any city or county
m which requires a Permit to co stract,Olin.improve,demolish,ar repair any suunum ?/2n $49500
thatWor siensedpa6a require the revisos.1 for Cchperm',Lieccs,Low(summcm r
< Ihethe lslianance.aom,wNc aponsnt the Canuaatarauc<nQignedsucment Sq.Ft. Floor Ar 3 Valuation
[�m (commencing with Section 700))of Division 3 of the Business and Professions Code)or ),
that k is exempt thmefrom and the basis for Banalleged exemption.Any violation of
Section 7031.5 by any applicant for a permit wbjccu due applicant m a civil perolty of T v OccU anC Type
nal more than Ove hundred dollen(5500). P Y YP
1,u ower of Ik pmpmty,a my employee with wages u Ik"v role compensation,
wall rNework andI To,Cera w,,Lksom car aRe does
set he sm camel of
c
and Pro he tau Cnde:To,Ce Bannon.Liam Law does or apply m an ower is Required Inspections
Own enywho s.prxrvulcd such improvements
who da hot in work Mmtlfor through his
ownemployee,provided prsuch improvementsaretat iouo(daroBaed fm sok If.
howeer.Ne Wilding or improvement Usold within oro yeti ofcompletion,theowar-
sale).r will have Ik burden of proving Nat k did rot build a improve for purpot of
sale.).
❑1,as ower of Use propert,am exclusively contracting with licused contractors to
construct the projea(Sec.7044,Business and Profusions Cade:)The Ondecoses V. _
cense law does not apply in an owner of property who builds or improves Norman,and.
whatta for such projects with aeonlracmr(s)liantd puyuammdu:Couct
naoYs IVr'faL\ll{s�(flyp t.'Jg �/pp/��1gy�atp$���.'-apff[�/a7�,
Licenseence Law
❑lam tempt undo See ,BhPCfor Nu arson
her Data
WORKER'S COMPENSATION DECLARATION SU,,..
1 hereby affirm under penalty of Perjury one of the fallowing declantianc
❑ I namond will malnuin aCcnifieats of Ccnwmwself-insure far Warkeri Conpen.
sation.as provided for by Section 3700 of the Labor Code,far Be pcRormarve of the ~1
were for which Nia permit is issued. ret ; t
❑1 haw:and will maintain Worker's Compemation Insurance as required by Section v
3M of the labor Cod,fw Ne performance of da work for which this permit is issued.
My Workeh Compensation Insurane,amu and Policy number am:
Cartier. t P,�c_ Policy Na.:SCJ.Ld.t1✓ d�p
CERTIFIGTE OF EREM MON FROM WORKERS'
COMPENSATION INSURANCE .
CITU section need not k c ompicred dust,permit is for enc hundred dollan(5100)
nr less.)
1 artily that in the efformsocc of the work for which Nis permit is issued,I shall not
employ any person in any manner an at N become subject in the Worneri Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT.If.after making this Ccruficam of Esemptian.you should
became subject in the Worker's Compensation provisions of the Labor Cod,you must
.J z forthwith comply with such provisions or NU Pani,dull be dcemcd revoked.
.zm O CONSTRUCTION LENDING AGENCY
'C+ 1 hereby affirm that then in a cmutrteur.lending agency far ft perfwmance of
a Nc work for which Nie permit is issued(Sec.3097,Civ.C.)
6W. Q Und is Name
Under',0. z nder's Add.
t.3 Q 1 eme(y Nat 1 lune and Nis application and tam this Ne chew information is
U. cortem.1 agree to comply with aft city and county omimnmes and sea laws slating to
0V building concoction,and hereby outhone,mpreaematives of this city to enter upon dm
�+a above mentioned pmperLysa for inspcctioa pur,parwhich m.
(We)agree to save,indemnify and keep named.tis City of Cupertino against
F'h Iia bilitie,judgments.cow and ea awhichmryin any way¢cot agmnsuaiO City
t.)z A in cont ANTU Rmn NDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date ��2.T—l/L
RC,
RE ATI NS.
LS U6 Re-roofs
SigmauofApptimUCon ter Dam `
HAZA US MATERIALS DISCLOSUR Type of Roof
Will The applicant car furore building occupanumre arhandle haeardaus malenal
u defined by the Cupertino Municipal Cade.Coupler 9.12.and,he Health and Smc,y
Cale.Safion 255324)? All roofs shall be inspected nor to an roofing material beim
❑res Na P P Y g g installed.
Will the applicant or future building occuptrut use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit Imandous air commonanu as de0md by the Bay Arco Air Quality Management all new materials for inspection.
Dieu ctT /
❑Yu PVag
I have real the Members materials requirements under Chapter 6.95 of the Califor-
nin Health h Safety Code,Satias 25505,25533 uW 25534.1 udcsmed Lha ifthe building
does not etmeady hoc a serol Nm it is my Maleans olfty to notify the occupied Of d¢
requiremaha which must k met poor to iguana ala Cetirmam of Occvpancty. Signature of Applicant Date
owner or.rthodr<d seem Dam .All roof coverings to be Class mB"or better