04080092 CITY OF CUPERTWO '"`" vim" :�3 �'"'`°"` a="
BUILDING DIVISION PERMITCONTR'AC�"TOR,INFORMATION
e, ..
BUILDING ADDRESS: PERMIT NO.
04080092
NER'S NAME: PERMIT LSUE DATE
ONE:
SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'S DECLARATION Job Description
w❑ 1 W reby affrm Nat 1 em licensed under provisions of Chapter 9(earn cocing
with 1�at�y670BB)ar Division 3 of Ne Bound Pmfcssiuru Code,and my Because is
infest: toile
'q_ Liansa G c- I 2rrA 1 h� REPLACE SHOWER/NEW VALVE SALE®
" c°ntr � �° � ONTRACTOR: KRUEGER KONSTR
Y ARCH( SOVATION
Y itkawlp 1 he d oretards
A. e 4 NOV
a03 Bar IAmBUILDER DECLARATION
I hereby maso affrm Net 1 1. exempt from the Contractors Cc License tsw far the
o O fallowing reason.(Station 703 1.5.Business and Professions Code:Any city or county
$2 which req.t.a peril to ennswct,alter,improve,d.Am,Ich,m.,air any atrvmum
FZ< prior un ib issuance,also requires the applicant for such remit to rile a signed statement
Nat he is licensed pursuantto the pavisiom of the Conuactur's License Law(Chapter9 Sq.Ft. Floor Area
,l n (commencing with Section 7000)o(Division 3 of the Business and Professions Cade)or
$ that he u exempt dmrefront and the baso far the alleged exemplic n.Any violation of
section 703 L5 by arty applicant for a Pamir subjects the applicant o a civil Penalty of APN Number Occupancy Type
not more man five hundred dollars($XAR.
01,as owner of he pMpcn,,or my employee.with wages as But,able compensation, 32653023 . 00
will do me work and memature is not intended oroRemd rorsale,(See.7044,Business
and Professions Code:The Conbacmfs License Law does not apply to an owner of Required Inspections
pmpenywha WEdsar improvesIn ncem..nd who daasuch.,it himself.,Enough his
Own employcu,provided theistical improvements are not intended oronemd forsak.If,
however,one building or improvement is writ within one Isar of completion,to awncr-
builder will hats the burden of proving that he did not build or improve for purpose of
alar).
❑1.as owner of Be prapeny,am exclusively conoutu,with licensed cant ecbrs Io
,..=I the project(Sec.7044,Business and Professions Cade:)The Conuacwri Li.
cemese Law does not apply in an Owner of property who Wilds or improves thereon,and,
who contracts for such projects wit a contractor(a)licensed pursuant to the ConvactoYs
L. Us
In under Sec. B h P C far^this..an
r Date d�'
OMP ATI DECLARATION
1 Mmby reffm under lena0y f red
o,=-1yo,ane of the following declaratiaw:
❑1 haw and will maintain a Certificate of Consent to self-imure for Workch Camper.
satian,As provided for by Section 3700 of the Ube,Code,for the ped roo.ta of the
work far which this lentil is issued.
❑1 haw and will maintain Worker's Compensation Imurance,As;required by Section
3700 of the Later Code,far the performance of the work for which this remit is issued.
My Worker's Compensation lnwmnce tamer and Policy number art:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crai section Med not be completed Rose(emit ts know hundred di laran)(Ind
ar teas)
1 certify that in the pc,fnmmec or the work for which Or.permil is issued,1 shall at
employ any person in an men�ns�ujohcgotpc/ u
ubjeco me Workcrs'COmPeuation
Uses of Celif,an,..
99 1I UU'' V`f
Appli vt
N E TO to dic or:IL after making Nis provisions
or of Limarhion,you should
J Obac omplm !I Worker's Comp A,this acraft oro o(Ine UW,tatkoyou mot
fonhwn comely`with such provisinm or this permit shall W deemed avokcd.
Z y CONSTRUCTION LENDING AGENCY
'ra I hereby affirm that them is a couwction lending agency for me pctfumancc of
2ahim,work fur which this pewit is!,rued(Sec.3097,Civ.C.)
D70 L,.&es Name
0, Z Undcts Address
U O 1 certify that 1 have read mice apricatian end sham ma me above infomahi m is _
W PCorrect.1 agree 10 comply with all city and county ordinances and stem laws relating to
QU building construction,and hem by authrds,mpresenmives of this city to enter upon the
W shave-mentioned pmpcny far inslecYoo proposes.
C (We)agree On saw,indemnify and keep hamless the City of Cupertino aponst
y liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z I in consequence of the grant a permit.
I ANT UND NDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
S C R IO i
V9_04 Re-roofs
nota / PPlicanUCamm or Data
HAZARY OUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or furore building Occupant store or handle harstdaus material
as defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Safety
de,Sued..255320.)? - All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applic t or fwum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cm it haremaw air canmminants feed by the Bay Area Air Quality Mansgcmcnt all new materials for inspection.
District?
❑Yes No
I have mad the hatardous materials requirements under Chapter 6.95 of the Califor-
ehyCoM,SatioM25505,25533 and 25534.1 undcrsmnd thus Role Wilding
ow not cum Y he a tenant.Inas i ms ihilihy at madly tM occupant of the
rcqulmAn hilt at PH issuance of ccnlfesmafOccupancy. lSignatureofApplicant Date
Gw. .wh.r i ant .Dam / All roof coverings to be Class "B"or better
_ y