04010132 CITY OF CUP
ERTINO
BUILDING DIVIs1ON PERMIT CONTRACT01 TNVORNIATION
BUILDING ADDRESS: - PERMIT"04010132
EWS NAME: PERMIT ISSUE DATE
RYA T0qYIJTiA
PHONE: SANITARY NO. CONTROL NO.
ARCHITER/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o O LICENSED CONTRACTOR'S DECLARATION - -
1 hereby affirm that I am licensedBu antler and
Protestants
Chapter 9(commencing Sob Deser ��
with Seniors 7(X1ef of Division 3 ofthe Business end Prafessinnx Cnde,and my license is
L'? m tensell Claanderrea' ADD 40 SQ. FT. /KITCHEN RElt4�(I�EI��
Date Clare Contractor
o,Q_,❑ Dam ComtacCL 20p^
�W V 1 understand my plans shall be used as DECLARATION
meords r Y
D vI Licensed Professional ��,�D1N/�'�
` I OWNER-BUILDER DECLARATION {�
.�<2 I hereby affirm that I am exempt from the Contractor's License Law ar the
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county _
which requires a permit to construct,aper,improve,demolish,or minor any structure
iy
poor o its issuance,also inquires the applicant for such Permit o file a signed statement
SSC that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation -
Ya' (commencing with Section 7")of Division 3 of the Business and Professions Code)or
i
but he is exempt therefrom and Ne basis for the alleged exemption.Any violation of �wniN,,R,�.A
Section 701.5 by any applicant for a permit subjects Ne applicanuo acivil penalty of 3 n'cs W V u+u VuerO 0 Occupancy�I e
not mom than five hundred dollars($AID). P y ' P
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do Ne work,and the structure isnot intended or offered for sale(See.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who buildsorimpraves thenen,and who does such work himselfor Nmugh his
own employees,provided that each improvement are at amended m abated for sale.If.
however,Ne building or improvement is said within one year of completion.lie owner,
builder will have the burden of proving Nat he did not Wild or improv,for purpose of
1,as owner of the property,ani exclusively contracting with licensed contractors to
me the of
(Sec.7044.Business and Professions Code:)The Contractor's Li.
case
law docs not apply to an owner of property who Wilds or improves human and -
ohoco21U for tucM1 projects with aconwnor(a)Ilcenutl pursuant to the Conuacto(a
�clantl Se ,B P fam"mason
R E COMPENS ON DECLARALT ..
I hereby aRtm under penally of perjury one of the following dedernl s:
0 I have and will pr ommin a Certificate of Consent to self-insure for Worker's Compere
ration,as presided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 ban and will maintain Worker's Compenaadon Insurance,as required by Section
3700 of the labor Code.for Ne as rformvue of the work for which this permit is issued.
My Worker's Compensation Insuramm carrier and Policy numWr am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
G COMPENSATION INSURANCE
(rhesaaction need not be completed if the permit is foram:hundred dollars(SRKB
or less.)
1 certify Nat is the performance of the work far which this permit is issued.I shall at
employ any person in any manner so ss m become subjecuo the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccdificam of Exemption,you should
become subject to the Worla's Compensation previsions of the labor Code.you must
Oforthwith comply with such provisions or this Permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
I hem by affirm that there is a construction lending agency for Nfe perxim sac of
lYi M the work far which this permit is issued(Sea.3097,Civ.C.)
W� Q Lender's Name
Z z Lender's Address
U 0 1 certify but 1 have read this application am stake that be above informuion is
UF, correct.i agree to comply with all city and county ordinances and state laws relating to
0. U building construction,and hereby aothorim representatives of his city to enter upon the
FU ehove-mentioneeeproperty furinipection keep es.
gy (Wc)acme to save, rugannif x,on and keep harmlcu the City of Cupertino againat
(nAWHI
gme me
and expenses which may in any way seem,against sold City -
C) 'z ,of the r ing of This permit.
^' U E STN S IAN
WILL COMPLY WITH �'ON?D T Issued by: 62 Date
G AT N -/)�UpRe-roofs I am/Comrumr DeHAZARDOUS MATERIALS DISCLOSURE Type of Roof
e applicant or future building menu anutore or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
m,Section 25532(a)1 All roofs shall be inspected prior to any roofing material being installed.
Ycs
Will Nc applicant o !marc building occupeni vu cyuipm,nt or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air crewman ;as defined by the Bay Area Air Quality Management all new materials for inspection.
Diatrict7
No !
If'. Wthemal sinnia Ith cl Code. c am25505.25533md25534.1undemundthmiflhc building
deef tl ba a n I. etitismymspon ilityto no y the me pans of the
rcymh al nor acemreak rq:c an Signature of Applicant Date
her a aamonv. a and l !/ re All roof coverings to be Class "B"or better
CITY OF CUP
ERTINO
BUILDING DIVIs1ON PERMIT CONTRACT01 TNVORNIATION
BUILDING ADDRESS: - PERMIT"04010132
EWS NAME: PERMIT ISSUE DATE
RYA T0qYIJTiA
PHONE: SANITARY NO. CONTROL NO.
ARCHITER/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o O LICENSED CONTRACTOR'S DECLARATION - -
1 hereby affirm that I am licensedBu antler and
Protestants
Chapter 9(commencing Sob Deser ��
with Seniors 7(X1ef of Division 3 ofthe Business end Prafessinnx Cnde,and my license is
L'? m tensell Claanderrea' ADD 40 SQ. FT. /KITCHEN RElt4�(I�EI��
Date Clare Contractor
o,Q_,❑ Dam ComtacCL 20p^
�W V 1 understand my plans shall be used as DECLARATION
meords r Y
D vI Licensed Professional ��,�D1N/�'�
` I OWNER-BUILDER DECLARATION {�
.�<2 I hereby affirm that I am exempt from the Contractor's License Law ar the
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county _
which requires a permit to construct,aper,improve,demolish,or minor any structure
iy
poor o its issuance,also inquires the applicant for such Permit o file a signed statement
SSC that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation -
Ya' (commencing with Section 7")of Division 3 of the Business and Professions Code)or
i
but he is exempt therefrom and Ne basis for the alleged exemption.Any violation of �wniN,,R,�.A
Section 701.5 by any applicant for a permit subjects Ne applicanuo acivil penalty of 3 n'cs W V u+u VuerO 0 Occupancy�I e
not mom than five hundred dollars($AID). P y ' P
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do Ne work,and the structure isnot intended or offered for sale(See.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who buildsorimpraves thenen,and who does such work himselfor Nmugh his
own employees,provided that each improvement are at amended m abated for sale.If.
however,Ne building or improvement is said within one year of completion.lie owner,
builder will have the burden of proving Nat he did not Wild or improv,for purpose of
1,as owner of the property,ani exclusively contracting with licensed contractors to
me the of
(Sec.7044.Business and Professions Code:)The Contractor's Li.
case
law docs not apply to an owner of property who Wilds or improves human and -
ohoco21U for tucM1 projects with aconwnor(a)Ilcenutl pursuant to the Conuacto(a
�clantl Se ,B P fam"mason
R E COMPENS ON DECLARALT ..
I hereby aRtm under penally of perjury one of the following dedernl s:
0 I have and will pr ommin a Certificate of Consent to self-insure for Worker's Compere
ration,as presided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 ban and will maintain Worker's Compenaadon Insurance,as required by Section
3700 of the labor Code.for Ne as rformvue of the work for which this permit is issued.
My Worker's Compensation Insuramm carrier and Policy numWr am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
G COMPENSATION INSURANCE
(rhesaaction need not be completed if the permit is foram:hundred dollars(SRKB
or less.)
1 certify Nat is the performance of the work far which this permit is issued.I shall at
employ any person in any manner so ss m become subjecuo the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccdificam of Exemption,you should
become subject to the Worla's Compensation previsions of the labor Code.you must
Oforthwith comply with such provisions or this Permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
I hem by affirm that there is a construction lending agency for Nfe perxim sac of
lYi M the work far which this permit is issued(Sea.3097,Civ.C.)
W� Q Lender's Name
Z z Lender's Address
U 0 1 certify but 1 have read this application am stake that be above informuion is
UF, correct.i agree to comply with all city and county ordinances and state laws relating to
0. U building construction,and hereby aothorim representatives of his city to enter upon the
FU ehove-mentioneeeproperty furinipection keep es.
gy (Wc)acme to save, rugannif x,on and keep harmlcu the City of Cupertino againat
(nAWHI
gme me
and expenses which may in any way seem,against sold City -
C) 'z ,of the r ing of This permit.
^' U E STN S IAN
WILL COMPLY WITH �'ON?D T Issued by: 62 Date
G AT N -/)�UpRe-roofs I am/Comrumr DeHAZARDOUS MATERIALS DISCLOSURE Type of Roof
e applicant or future building menu anutore or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
m,Section 25532(a)1 All roofs shall be inspected prior to any roofing material being installed.
Ycs
Will Nc applicant o !marc building occupeni vu cyuipm,nt or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air crewman ;as defined by the Bay Area Air Quality Management all new materials for inspection.
Diatrict7
No !
If'. Wthemal sinnia Ith cl Code. c am25505.25533md25534.1undemundthmiflhc building
deef tl ba a n I. etitismymspon ilityto no y the me pans of the
rcymh al nor acemreak rq:c an Signature of Applicant Date
her a aamonv. a and l !/ re All roof coverings to be Class "B"or better