04020145CITY OF CUPERTINO
t
CONTRACTOR M`•°�"Ty '
BUILDING DIVISION PERMIT
BUILD ]NO ADDRESS:
PERMIT N'04020145
OO4(]20145
NER'S NAME:
PERMIT ISSUE DATE
EI
SANITARY A02. CONTROL NO.
ARCHITECf/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB NIECE0
0 e! I�
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby affirm Nat 1 am licensed under provisions of Chapter 9 (commencing
with Stolon 70118) of Divishun 3 ofthe Bulinus and Professioas Codc,and my license is
in full rose and effcet
FT
ADD 168 S Q /KITCHEN REMODEL
Limmc Class Lic.p
. .
Dem Connector
ARCHITECT'S DECLARATION
1 understand my plans shall W used as public memtls
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aRrm that 1 am exempt from the Contractors License Law for the
,
follnwing mason. (Section 7131.5, Business and Professions Code: Any city of county
which requires a permit at ennsimcl, alter, improve, demolish, or repair any structure
prior to its issuance, else mquiru the applicant for such permit to file a signed simemsel
Ft. Floor Area
Valu tion
that he is licensed pursuant to the provisions of the Cmuacmh License U.(Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
Nat he Is exempt therefrom and the basis for the alleged eccentrics. Any violation of
3�Igdp�grp p
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom Nan flue hundred dellen (5500).
❑ 1, as owner ofthe property, or my employees with wages u their sok conspensaton,'
Required Inspections
(I
willda the work, and lhesl(uctum is notimended oroRemd forsale(See. 7044, Business
and Prolamines Cade: The Commutes Limose Law does net apply m an owner of
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property who builds r im proves thereon, and who does s uch work himself or through his
ownereployees. provided thmsuch improwma es see not inrerdedaroBemd rorsala. IL
not build or improve rte purpose owner.
i that within
will have the burden of improvement
holeyhowever. the building or Improvement la hale within on year of completion, the eof
Q
omnuacmrs to
e owner of the property, , Business s and connecting with Code:)
Tons met the project (Sec. 704q Codei The GBrltrereon, Li -
ownerofand propertywho.builds
who contracts for such projects wifea ntracmr(s)flunse0 pursuant mthe Gantramerl
LKCaY LB
/
❑1 e m nerstt. .B&PCI....
�ar�thias�5
Owner ke Da
y
WORKEIrS COMPENSATION ATION
1 hereby alarm under Penalty of perjury one of the following dedas lkne:
I hive and will maintain a Certitcom of Consent to sel4insure for Worker's Compere
sation, as provided for by Section 3700 of the Labor Code, for W performance of fee
work for which this permit is named.
'
❑ I have and will maintain Worker's Compensation Insurance, as required by Seedon
3700 of the labor Code, far fee performance of the work for which this permit is Trued.
-
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
IGts section need not W completed Eder permit is Income hundred do[hua ($I00)
Icsa)
1 certify that in the performance of the work for which this permit is issued, l shall not
employ any Person he any manner se as in became subjecu. the Workers' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
he oma Subject m the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit mull W deemed rmulmd.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I hive mad this application and sum that the aWw, inf.rmauun is
corteot. I agree to comply wife all city and county anlimances and sate laws misting in
building construction, and hereby aufemire representatives of this city to enter upnn the
above-mentioned properly for inspected purposes.
(We) agme to save, indemnify and keep harmless the City of Cupertino against
habllides. judgments, costs and expenses which may in anyway accrue against said City
in coroeq ce egranlin8 o(Ih' rmil.
iAPPI.n..
IN ERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by:9 Da
R EGUL 0
r Z'2o'
Re -roofs
Type of Roof -
toof Applican n r Dale
re
HAZARDOUS MATERIALS DISCLOSURE
Willapplicant or furore buildingeapt arum or hudlc homeosesmaterial
Wf
as defined y ft Cupertino Municipal Cade.. Chapter 9.12. and the Health and Safely
.
Code, oyeS 2ss32(a)?
All roofs shall be inspected prior to any roofing material being insialled.
NNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fat" um bLilding occupant use equipment at devices which
met, hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
13 Yes u
Ihnce the smaoniak mquiroments under Chapter 6.95 offec Caliper,
ria Hod &S adc, Sc 'oas25-105, 33ud25534.lundcntandfeatif& Wiiding
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does not t haw e ¢ n4 Nat it' y msponsi�ih nuul'y the occupant of fee
myuimon len . pd. ahaan.coraceni0ca .r(xeapan.y.
Signature of Applicant Date
2 20All
roof coverings to be Class •'B" or better
mer ser authorized agent Bob,