08050118 CITY OF CUPERTINO ./-� :�«.s.�'s.�♦%�-..� /'� "��y&az "` ' ' �;'s�T
BUILDING DIVISION PERT
PERMIT NO.
au1LQIr�cApq(cEsUPLAND WAY TBD — T0. BE DETERMINED 08050118
!'ONE:NER'S NNA.SMEE: PERMITLSSUEDATE
KATHY KHODI 06/26/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u OLICENSED CONTRACTOR'S DECLARATION
1 hereby aRrm Wal 1 iso li¢vW under provisions of Chapter 9(CommercialJob Description
.Section7IX )of Diviaion3of We Busin=and Nofc&io.Code,.d-,Ii,--Is ADD 684 ' LIVING RM, STUDY, LAUNDRY RM,BATH & PORCH.
iq? uaex cins`d`ff"L Llc.is REMODEL KITCHEN(200SQ)LAUNDRY & DINNING
Dam.ContributorARCHITE
CTS I undcraund my plans ahallhe used DECLARATION
Public records; RM(15 0 SQ) .
rTlm�
5nU
g t; Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hereby M.that 1 em exempt from We Contractors Lmmx Law for the
0 O following meson.(Section 7031.5.Business and Pofcssiou Code:Any city or county
e$ which requires a permit o c..L alter,improve,demalbh,ar repair any swmuse
'mit prior b is issuance,also requires the applinm far such permit as rile a signed sutemem
< Sq.Ft. Floor Area Valuation
that he is licensed pursuant to We provisions of gasConwcmri License Law(Chu pmr 9
YDS (commencing with Section 1000)of Division 3o(the Business and Pmfcuions Code)or $80000
that be Is exempt WaOfrem and the hub for We alleged exemption Any violation of
Section 1031.5 by airy applirsnt(t a permit subjects the applicant to a civil penalty of p, Number Occu ane
not mom than fiat hundred dollars(SM 36603055 .'l7'V' P y Type
1,u owrcr of robe properly,m mY employes with wager u tie'v xis eompenution,
will do the work end Weawdure is not imended or offered i..sk(Sc.1014.Busimss
and Professionals Cade The Contractors Liccue Law doe an,apply to an Owner of Required Inspections
property who bu ilds or im prows thereon,and who dues such wort himself m though his
awn employ=,provided thatauch improvements art not immnded or Offered for sale If.
however,the building or improvement Is sold within am)ear of completion,the Ownv-
builder .will haw the hurder of proving that he did her Wild or improve for purpose of
ub.).
1,as awner of the property,am exclusively cor muting with licensed mnwclort ta
Consumer the pmjecl(Sec.1004.Business and Professions Code:)The Coovacor's U. -
«nse Law d=not apply to an owner of property who builds or improves theman.sed. ,
who contracts for such projects with a can0xor(3)licensed pursuant m the Conu.tors
License Law.
❑lam nempt and S Dam PC fpr Wu aaxP
Dam
W ORK 'S FNSA ON DECLARATION
I hcxby.farm u:perWtY of perjuryare Of Oa rolum ing declaratiou:
❑Ih,m esW w0lmainuin•Cenifiax O(Conxnto self-insurtlmWorkersCompen-
xtion,a3 Provided fm by Section 3'1110 of the Lsbm Code,fur We parformano Of the
work for which this permit is issued.
❑1 have and will maintain Worlds Compensation I..ss Inquired by Secuon
3100 of the labor Code,fm de performance of the work for which this permit Is iamb
My Worker,Compensation In.all.am=end Policy number am:
Cartier. policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mus xmoe recd not ba compleed if the permit Is(mom hundred dollar(5100)
or bas)
I rerelly dust in We perorma ce of the work for which this permit is issued.I shall am
employ..,penon inD..[pP'y�mgpaOner��sqosso brs�c subject sup the wtkeri compensadem
Law,of Caliromia.
APPlicant /LArPI fM !%sem
NOTICE TO APPLJCANT.If..Mr .king this Ccturzeno of Exemption,you should
become subject m the Wad c s Compensation provisions of the letter Code,you most
wJ z foMwiW comply with such Provision,m this permit shall be decmrA revalued.
z O CONSTRUCTION LENDING AGENCY
[—� I hereby drim Wu them is a commuction lending agency for the Performance of
a> the wok for whim this permit is named(Sec.3097,Civ.C.)
Lenders Name
z leader,Address
U O I unify chat 1 have had this applicadon and sum that the allow information is
LL,F corset.I agree o comply with all city and county ordinances and euro laws reading in
0 U building construction,and hereby authmice representatives of this city m enter Open the .
shove-memiarca popery for Inspection.whichpurposses.
F y (We)agree m ave,indemnify and LOOP bamlea the City of Cupertino again
Z in Conseq enceO the
and upensuraft. may in any w,y acrnca&ainst said City
Uz APLICAN Consequence Or the RSTAN of AND WIL �� ��
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 62� Date 6
SOURCEREGU�` °N ��
E' ^ s4ta��< �n Re-roofs
Smgnawrt of Ap licaHAZARxm p
HAZARDO(; MATERUALSDISCLOSURE Type of Roof
Will the Cupert oc tino
Muni Wilding ode.Chart nor m handle HWLh and Seely '
ss defined ..We Cupertino Municipal Code.Chapter 9.11,and the Hdth and S.fety
.Sctbn 155324)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future Wilding eeeu nt rex If a roof is installed without first obtainingan inspection,I agree to remove
pp g pe equipment Or Marta which P
Call TSNous air conuminuts u Jcfincd by Ne Bay Area Air Quality Management all new materials for inspection.
Y., ❑Nu
1 have real the huaNws materials bequimments under Chapter 6.95 of the Calling,
nb HealW&Safcty Cade,,Secuma15505,15533w115534.1undcnandthai(dc building
does mot currently haw•enam,dot it b my rupomibany o Wary de meupent or We
requirements which= comet ' ro isuaw oft Cenirttm Or Occupancy. Signature of Applicant Date
Owner or affhan,,ad agent P Drum All roof coverings to be Class'%q"or better