04060079 CITY OF CUPERTINO
BUILDING DIVISION PERMITWC
ONTRACTOR IrrFaM .TIo t
BUILDING ADDRESS: PERMIT N00 4 0 6 0 0 7 9
2,3300 VIA ESPLEND
LINER'S NAME: PERMIT ISSUE DATE
\ 06/09/2004
E: - SANITARY NO. CONTROL NO.
ARCHITEC FENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z1
with llforcnndeffecDivision 3ofthe BuvnussoralProfesaiumCoM,and myliccnais INTERIOR REMODEL (KITCHEN/BATHRM/CLOSET/WALLS)
m fun a Class tl effect.
�? License ClassLlh.
ppp Dam C.M m
ARCHITECTS DE DECLARATION
1 understand my plans shall insured u public rtcnrth
3 Licensed Professional
OW NER-BUILDER DECLARATION
I hereby affirm that II exempt from Ne Conlrecon's License Lew for the
O O following mason.,(Section 7031.5,Business and Professions Code:Any city Of county 30000
which rtqulm+a Permit to construct,alar.improve,demolish,or repair any structure
' prior.is issuance.also requites the applicant for such permit to Bl,a aignedauom,m
�< that he is licensed pursuem m the provisions of Ne Contractor's License Law(Chapter 9 Sq.Ft. Floor Area
FZVa nation
(commencing with Section 7000)of Division 3 ofthc Bu ass and Professions Code)or
Wt he u exempt thcmlro.and the basis for the alleged...,due Any violation of
Section 7031.5 by any applicant for a penult subjects the applicant to a civil penalty ofe 0 Occupancy Type
ML mart than fin hundred dollars($500).
❑1,ummrofthepmpeny,ormyemployceswiNwagesastheirmlecompen+mien,
will do the warkend Nnswmum isnotinundedoroRered mraelc(Sm.7044,Business Re uired In C ons
and Professions Code:The Contractors License Law does not apply to an owner of q
properly who builds or improves mersenond who does aeh work himalf or through his
own employms,pmvided thatsuch lmprovemenu m notimmnded oroRemd forale.IL .
however.Neave ingarimpmvementismldsedid one Weer of completion,Nrpose of is _
howev will have tin Wmenro proving Nu W did oat ear or l.praa for purpose r.
/
Ii u sever of the property,.B exclusivelynd caniracting Cod:)TheA mm ecmu U.
D/
e La d project(sec.7014,Business end property
who i Code:)The Convenor's rad
e taw Cats not apply a an owner of properly who Wilds or improves Neeson,and /
who contracts for such projects with acontrecmKU llumetl punuenlmNe Convecpora '
License Law. - D
❑lam ezem ntle .B&PCfOflu
nor Dam O
WORKER' OMPENSATION DEC ftATI
I hereby affirm under penalty of pCjmy one of NC fo owing declarations:
have and will..!main.Cerlifru,of CMI.self-insurefor Workers Compcn-
sation,as provided for by Section 3700 of dm Labor Code.for th,performance of the
work for which this permit is issued.
❑I he
and will maintain Workers Compensation Insurance,as required by Section
3700 mf the Labor Code.for Ne performance ofthe work for which this permit is issued. -
My we
Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: +
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olonvoction need notal completed if the permit is faros,hundreddedlars($100)
Or IOm.)
I certify mat in the performance of Ne work for which this Permit is issued,l shall not
employ any person in any m uneran az to become subject to the Workers'Compentatlon
Low of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this C,niftceu of Exemption,you should
become subject to the Worker's Compensation provisions,(Ne Labor Code,you must
Q Z forthwith comply with such provisions or this Permit shall W deemed revoked.
'ZO CONSTRUCTION LENDING AGENCY
E(Yi
1 hereby affirm that Nem is a construction lending agency Car the performance of
r>. Ne work for which this permit is issued see.3097,Civ.C.) _
WMQ Leaders Name
0.. z lender's Address
U Q I cenify that 1 have most this application and sea that the above inrm.ation is
4, f~' Conect.I agree 10 comply with all city and county onfinances and supe laws relating o
QU building constmetion,and hereby suNoria repmsenutivef of this city to enter upon the
W shove-mentioned property for inspection purposes.
gy (We)agree to save,indemnify and keep humless the City of Cupertino against
,y y liabilities,judgments.costs and expenses which may in any way same against said City
U in consequence of NC granting of this permit.
APPLICANT UN STANDS AND WILL COMPLY WITH ALL
/N/ON-POINT Issued by:
6 Date
SOU
DAYJ
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne a Cupertino
or(Mose building me Chapter
atom or hanand the
Health and
C defined io the Cupertino Municipal Code,Chaper 9.12,and the Hca1N and Safety
Code,S 3 on]5532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
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
t havardous air comeminans as defined by the Bay Area Air Quality Management all new materials for inspection.
Isuiel?
❑Yes No
1 have mad Ne hasandn s materials mquimmcnu underCWpmr6.95 of the Califon-
nieHealN&SofclyCode,Sections 25NI5.25533 and 26534.1 unCcrsmnC NetifNc building
does n01 CunCnlly hove a mnen4 Nal it is my mSpemihihly a n0dly NC IX:CYPanI of mC
All roof coverings to be Class"B"or better