04090038 C[TY OFCUPERTINO °^ *_'* t: "7
BUILDING DIVISIONPERMIT CONTRA@TOR�INRMATION -
. 41&1
BUILDING ADDRESS: - PERMIT N0.0 4 0 9 0 0 3
OWNER'S NAME: PERMIT ISSUE DASH
i
lEo - SANITARY O *OL NO.
ARCHITECT/FNGINEER: BUILDING PERMIT INFO
BLDG EIEC? PLUMB MECH
p 0
+fOQ LICENSED CONIRACfOR'S DECLARATION
�j I hamby alBifa that I ao flamed under provisions of Chapter 9(Commencing _ Job DPSCripIl00
with Section 7000).f DIW,ian 3 ofdm Basimas,nd Profession Code.end my license is
mmumrtemeartea KITCHEN ADDITION/REMODEL
Z License Class Lic.Is
Dam Contractor
ARCHITECTS DECLARATION
I unduaand my plans Mall W used u public records )
3�
y sad
Licensed Profcssiond
OWNER-BUILDER DECLARATION
I hereby so affrrm IMII 1. exempt from the Contractor's o License law for 1W
O o following recon.(Sadao RDI tr B,alae upr Re. am li Code:Any city or county
$�
which am ima a permit to construct,alter,improve,demolish,nr repair my umcmm
F Z Ln prig m its is sed muse rtquifa lab apPOCwil for mcMMICIO l torileLawd eummem
FF 0 (last tom icllanmdpurmammNcpmvivision the oftheBmcesanianxlawlCMpmr9 Sq.Ft.Floor Area Valuation
ii
(commencing with Section700(hand of basis f r the
al alleged
axe and t proon.Any
Cade)or
3$ du1 he h extmpt 0mrefrom and me bola for Ne umgcd exemption.Any violelim of '
Section 7031.5 by cry appilmnt(.a permu mbjeets me applicant to a civil penalty of 3 2RN(MftL er 0 0 Occupancy Type
Out mom mm five hundred dollars($500).
❑I,uownerofinepmpaty.mmyemploytuwimwgnumeirmleampemmion,
will domewank ands- muammrenot Inmadetl,Law
mpply to an,Buaimu
will do the moons Cade:The Canuado,i Liana law dao ran,m apply man OwnerEmblem
of Requ- tions
property who Wilds rimproves thaeou,andwha daeaxueh work himsel(or through his B
own employ=.provided that such Improvements arc not Intended aroRered forsale.If. L
howmsr,me building ar improvement Is sold within ode)w of impletion.the comer.
bullder will hue the burden of proving met he did not build or Improve for purpose of -
sale.). DEC
(([[�� a owner of the property,em emlualvely contracting with Deemed antnmasa U. rj 9/)nr
read U W Prolec+(Sec.]01a,Buinesa and Profadons Cade:)The Ciusemr'a Li- 'J7
ma law dues am st PIY m m owner of propeaY who Wilda or improv Ncrtmt.and.
who conmcu for such projects with 4 contramor(s)lianadpunumit to the Con axamel gay
Qat aea
m em Sec .B A,PC far this
Owner Dated G d t—t
ON DEC RATION
1 reby ala oder puWly a(pajury orc of the fo 'ng declwioac
1 hew and will mountain a Cenlriate of Cmuxm mself-Imam for Worker'.Compcn.
come.an providrA for by Section 37001 of ore Labor Cade.for the Performena of me
wank for which this permit is issued.
❑1 have and will maiatsin Worker's Compensation Inarana.u required by Sued.
3700of ma Labm Code.for the NH...of me vark(ar which this perotb is h ad.
My Worker's Compensation Inmrwia caries and Policy number art:
Carrier: Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Gb6xcdw need tot he completed lithe peseta isles.huadredd.11.4100)
or lens)
I madly met in the perfurmancc of me wart fa which this Permit Is luded,I shell not
employ enypermn In my meaner to as m became mbjeel to the Walken{CampeNe110n
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate or Exemption,you should
become mbjw to the Worker's Compensation provisions of the labor Coda you must
0 Q forthwith comply with ouch provisions or this Permit shall be deemed revoked.
Z► CONSTRUCTION LENDING AGENCY
EI hereby affirm that them is aconmucam,leading agency far do performance of
> the work fm which this permit I.issued(Sec.3097,Cih,C.)
III Q Lcndcfa Nunc
=Z Lender's Add.
U Q 1 madly that I have read thus application sad sum that the above information is
ly correct I agree 10 comply with all city and county ordinances and sate laws missing to
V building communion,and hereby suhorim representatives of this city to caw upon the
W shove-memioned property for inspection purposes.
(We)agree to save,indemnify and keep hi mium the City of Cupertino against
fdjt
liabilities,judgments,costs and expenses which may in my wry accrue against tend City
U 7 in co a of the gating of this Permit.
�7 APPLI l l'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU GULA717 IS r
Re-roofs
arta UCannsmDam
HAZARof S MATERIALS DISCLOSURE Type of Roof
Willth applicant or fu0uc building occupant uRrc or handle hamolous mamriu
u defined by the Cupertino Muni'pal Cade.Chapter 9.12.ab me Holm and Safety
Code.Section 25532m)? All roofs shall be inspected prior to any roofing material being installed.
pYa No
Will me applicant or lulu Wuamg aeapant as equipment car demons whish If a roof is installed without first obtaining an inspection,I agree to remove
It hasaNau air intaminmts dc0ad by me Bay Amon Air Quality Management all new materials for inspection.
District?
❑Ya Nu
Ihave mad the hmaMausmucrlalsmyulmmenuunder Chapmr6.95ofmc Califon-
nix Halm alctyCode,Satiov 25505.25533 and2533e.1 undcmvd malflW Wilding _
data not elly have mm t,041 It is my responsibility m notify the OmUPml of me
require hichon t mucissumcafacctificacor wy4 Signature of Applicant Date
cbsalarath . cut , Data All roof coverings to be Class"B"or better
C[TY OFCUPERTINO °^ *_'* t: "7
BUILDING DIVISIONPERMIT CONTRA@TOR�INRMATION -
. 41&1
BUILDING ADDRESS: - PERMIT N0.0 4 0 9 0 0 3
OWNER'S NAME: PERMIT ISSUE DASH
i
- SANITARY O *OL NO.
ARCHITECT/FNGINEER: BUILDING PERMIT INFO
BLDG EIEC? PLUMB MECH
p 0
+fOQ LICENSED CONIRACfOR'S DECLARATION
�j I hamby alBifa that I ao flamed under provisions of Chapter 9(Commencing _ Job DPSCripIl00
with Section 7000).f DIW,ian 3 ofdm Basimas,nd Profession Code.end my license is
mmumrtemeartea KITCHEN ADDITION/REMODEL
Z License Class Lic.Is
Dam Contractor
ARCHITECTS DECLARATION
I unduaand my plans Mall W used u public records )
3�
y sad
Licensed Profcssiond
OWNER-BUILDER DECLARATION
I hereby so affrrm IMII 1. exempt from the Contractor's o License law for 1W
O o following recon.(Sadao RDI tr B,alae upr Re. am li Code:Any city or county
$�
which am ima a permit to construct,alter,improve,demolish,nr repair my umcmm
F Z Ln prig m its is sed muse rtquifa lab apPOCwil for mcMMICIO l torileLawd eummem
FF 0 (last tom icllanmdpurmammNcpmvivision the oftheBmcesanianxlawlCMpmr9 Sq.Ft.Floor Area Valuation
ii
(commencing with Section700(hand of basis f r the
al alleged
axe and t proon.Any
Cade)or
3$ du1 he h extmpt 0mrefrom and me bola for Ne umgcd exemption.Any violelim of '
Section 7031.5 by cry appilmnt(.a permu mbjeets me applicant to a civil penalty of 3 2RN(MftL er 0 0 Occupancy Type
Out mom mm five hundred dollars($500).
❑I,uownerofinepmpaty.mmyemploytuwimwgnumeirmleampemmion,
will domewank ands- muammrenot Inmadetl,Law
mpply to an,Buaimu
will do the moons Cade:The Canuado,i Liana law dao ran,m apply man OwnerEmblem
of Requ- tions
property who Wilds rimproves thaeou,andwha daeaxueh work himsel(or through his B
own employ=.provided that such Improvements arc not Intended aroRered forsale.If. L
howmsr,me building ar improvement Is sold within ode)w of impletion.the comer.
bullder will hue the burden of proving met he did not build or Improve for purpose of -
sale.). DEC
(([[�� a owner of the property,em emlualvely contracting with Deemed antnmasa U. rj 9/)nr
read U W Prolec+(Sec.]01a,Buinesa and Profadons Cade:)The Ciusemr'a Li- 'J7
ma law dues am st PIY m m owner of propeaY who Wilda or improv Ncrtmt.and.
who conmcu for such projects with 4 contramor(s)lianadpunumit to the Con axamel gay
Qat aea
m em Sec .B A,PC far this
Owner Dated G d t—t
Co
I NS ON DEC RATION
1 reby ala oder puWly a(pajury orc of the fo 'ng declwioac
1 hew and will mountain a Cenlriate of Cmuxm mself-Imam for Worker'.Compcn.
come.an providrA for by Section 37001 of ore Labor Cade.for the Performena of me
wank for which this permit is issued.
❑1 have and will maiatsin Worker's Compensation Inarana.u required by Sued.
3700of ma Labm Code.for the NH...of me vark(ar which this perotb is h ad.
My Worker's Compensation Inmrwia caries and Policy number art:
Carrier: Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Gb6xcdw need tot he completed lithe peseta isles.huadredd.11.4100)
or lens)
I madly met in the perfurmancc of me wart fa which this Permit Is luded,I shell not
employ enypermn In my meaner to as m became mbjeel to the Walken{CampeNe110n
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate or Exemption,you should
become mbjw to the Worker's Compensation provisions of the labor Coda you must
0 Q forthwith comply with ouch provisions or this Permit shall be deemed revoked.
Z► CONSTRUCTION LENDING AGENCY
EI hereby affirm that them is aconmucam,leading agency far do performance of
> the work fm which this permit I.issued(Sec.3097,Cih,C.)
III Q Lcndcfa Nunc
=Z Lender's Add.
U Q 1 madly that I have read thus application sad sum that the above information is
ly correct I agree 10 comply with all city and county ordinances and sate laws missing to
V building communion,and hereby suhorim representatives of this city to caw upon the
W shove-memioned property for inspection purposes.
(We)agree to save,indemnify and keep hi mium the City of Cupertino against
fdjt
liabilities,judgments,costs and expenses which may in my wry accrue against tend City
U 7 in co a of the gating of this Permit.
�7 APPLI l l'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU GULA717 IS r
Re-roofs
arta UCannsmDam
HAZARof S MATERIALS DISCLOSURE Type of Roof
Willth applicant or fu0uc building occupant uRrc or handle hamolous mamriu
u defined by the Cupertino Muni'pal Cade.Chapter 9.12.ab me Holm and Safety
Code.Section 25532m)? All roofs shall be inspected prior to any roofing material being installed.
pYa No
Will me applicant or lulu Wuamg aeapant as equipment car demons whish If a roof is installed without first obtaining an inspection,I agree to remove
It hasaNau air intaminmts dc0ad by me Bay Amon Air Quality Management all new materials for inspection.
District?
❑Ya Nu
Ihave mad the hmaMausmucrlalsmyulmmenuunder Chapmr6.95ofmc Califon-
nix Halm alctyCode,Satiov 25505.25533 and2533e.1 undcmvd malflW Wilding _
data not elly have mm t,041 It is my responsibility m notify the OmUPml of me
require hichon t mucissumcafacctificacor wy4 Signature of Applicant Date
cbsalarath . cut , Data All roof coverings to be Class"B"or better