04030017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT , +� IZ�L'TQ ';�A."CIUN �:
BUILDING ADDRESS: ARTISTIC KITCHEN DESIGN PERMIT NOO 4 O 3 O O 17
1127
ER'S NAME: PERMIT ISSUE DATE
KIF & NORMAN BR
ONE: SANITARY NO. CONTROL NO.
(650) 390-9615
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
p BLEG ELECT I-O O PLO O
+100 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
<n� win Section Division 3 of the Business and Professions Code,and my license is
in mu ma�.gR'd ercem.TO 8/6678 EVISION -IN HOUSE USE ONLY
�Z Wcense SC""[ _lam
Dam on DEC RMIT ISSUED/ORIG. #04020067
ARCNITECLSRAT10N-
1 understand my plans shell W_ Uu�i unECIaAo Bc records"
7y
LGA' Licensed Professional
OWNER-BUILDER DECLARATION
99 I hereby maxo .(Sero that 11. ,Business
s an the Conlon Co License saw for she
i O O fallowing naso-. mord,t 7(131.5,Business and improve,
de cos Code:Any city s county
v$ which mqussu•permit re c�res Me tutee improv,demolish,ri repair ed ssrucmre
Mery m its issuance,also requires to Me the applicant for such ponce m Bic a signed amtement 3 4
�FF�< (Men comma ccenud pursuanttome of Divionsnf MeCommencesBusiness Li¢nuiaw(Chapttt9 Sq.Ft.Floor Area Valuation$
C $ that he
exempts Section 7M)of ussion3Mlhecgeinenandon.Any
Code)or
that he b exempt thmefrom roti the bash for me mlcgcd escmpdm.Any violation of
Section 7031.5 by any applicant fon permit subjects rte applicant In a civil penally of APN Number Occupancy Type
rens mots nen five hundred dollars(5500).
❑1,as owner of 1W property,or my employers with wages as theirsole compensation, 35625008 . 00
wind.the work and the net..isnnimandcd oroffered tarsal.(Sec.7044,Business Required Inspections
and Professions Cade:The Commences License Law does Ices apply m an owner of q p
property who builds m i mpmvea nercon,and who does auch woh himsel f.r through his
own employees,provided Ihmsuch improvements me not intended oroRered fornle.IL
however.me building or improvement is sold within one year of completion.the owner-
builder will have de burden of proving mat he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively commoing with licensed conoscsom to a^,�
construct the project(Sec.7044,Business and Professions Code:)The Connacml6 U. ✓ \
cause law docs not apply to an owner of property who builds or improves Ihemon.and I C'
who contracts for such projects with aeontncnKs)licensed pursuant in the Contractor's
L*Oman
Law.
exempt under ,B k P C for this mason
Dem /
K CO fPENSATION DECLARATION
1 mB oder penally of perjury one of the following declmatimu: -
[Lave and will maintain a Certificate ofConsentm sel6inmra for WorkeesCompen-
aation,es provided for by Section 3700 of me Labor Code,for the perfomence of the
work for which this Permit is issued.
0 I have and will maintain W.rkees Compensation Insurance,as required by Section
3700 of the Labor Code,for me performance of me work for which this permit is Issued.
My Worker's Compenuiion Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuction need not W completed If she Ismailia fomnc hundred dollen(5100)
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 avast. comesubject to to Workers Compensation
Laws of California.Dan� 5LT3.�
Appli ns
NOT APPLICA"::IC;5��a r )m is Ceni mate of Exemption,you should
beco a jest m me WORer'eQa Ipg tion proviaiom of rte lahnr Cnde,you nun
.,O foM m comply with such provisions or this Permit shall be deemed revoked.
'Z r~
y. CONSTRUCTION LENDING AGENCY
F I hereby Office that there is a construction lending agency for the performance of
ai ,7 me work for which this permit is issued(Sec.3097,Co.C.)
0. Q Lender's Name
z Lender's Address
U Q I certify that 1 have read This application and ante that the above informed..is
ly Pconed.I agree to comply with all city and county omin1 eel and mate laws miming to
O C) building construction,and hereby mthmine mpreselAnIM of this city to enter upon me
W above-mentioned property for inspection purposes.
(We)ague to save,indemnify and keep harmless the City of Cupertino against
„y,0.A Ilabilisies.judgments,costs and expenses which may to any way accmn against mid City
U Z in consequence of the granting of this permit.
ti APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 670 Date
SOURCEREGUL
3 T eU Re-roofs
ig sere o I' HA ARDOUPlm ch"S MATERIALS DISCLOSUR� Dam Type of Roof
W4lLde ansor future building occupant store or handle haasrdoua material
ticfmcd by me Cupertino Municipal Code.Chapter 9.12,and me Health and Safety
❑Ye
.Scction25532(a)? All roofs shall be inspected prior to any roofing material being 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
.mit ha'rardous airuontsminams as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes u
Ihavemadthehm usmamrialsmquimmenuunder Chepwr6.95aftheCalifor-
nia Health dr S eiyCod..Senions25505,25533 and 25534.1 mde nand Medina building .
docs not come, haw a moan met It is my responsibility m notify me occupant of me
requircmcn hichmust cprio uanccofaCmuficx` fZ4cup _31ZI Signature ofApplicant Date
Dwntt.,mdhu ,d Dme All roof coverings to be Class"B" or better