04090016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDINGADDRESS: PERMITNO.04090016
OWNER'S NAME: PERMIT ISSUE DATE
SANITARY O OL NO.
ARCHf1EC 7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
m
30p LICENSED CONTRACTOR'S DECLARATION Job Description
d I hereby aMrm that 1 em licensed under provisions of Chapter 9(commencing
with Sedan 7000)of Division Sof mo Busirteu and Professions Cade,and my Bcenseh
in full farce aid efface.
Llemme Class uc,g ADD 40 SQ. FT. /KITCHEN REMODEL
a
Data Can
R
tractor
ARCHEC on DECLARATION
1 understand my plans shall M used as public records
36
hc Licensed Professional
OWNER-BUILDERexeptDECLARATION
Of I hertmy.OffirmSu Net 11. exempt hum the Comes Co license Lew,for IM
O O fallowing reason.(Sutton 7(1713,Business and Pmfuaions Code:My city or roomy
S which ragdree a permit w crearrecl,aIle,improve.demolish,or repair my suuomm
�Sa prior to its issuance,also requires meappliemt forsuch permit to file a signed mtemem
gFp C that he is licensed punuent to Lisa previsions of the Contracmr's License law(Chapter 9 Sq.Ft. Floor Area Val a IOn
3a (commencing with Section 7000)of Division 3 of the Bmheerand Profusion&Cole)or
Nat he is exempt thctef em and the bash for the alleged eamption.My vialarlm of ntuwi�y7..i bb,,
Section 7031.3 by any applicant for a Permit aubccu In the aPpOunt a civil penalty of 3�Dalr viv�mYv-f O 0 Occupancy Type
Out mare men five hundred dollars($500).
❑I,a"nor of the property,m my employee with wages as their role compeawtion,
will da the work and the$Mon.Is not intended e.Qertd tarsale(Sec.7044,Bminese
and proportion,Code The Conmctot's License law dace an,apply a an owner of Required Inspections
propenywho builds or Interim thereun,and whodauauchwek himselforderough his !,
mvnemphryeu,provided thalsuch Improvement,lee not intended molfcrnd for We.If. /
however,the building or improvementear is sold within arc yofmmpledm,the owner-
saeder .w10 have dor hvdrse of proving that he did not Wild m improve for purpose of
build.
as..or of me property,am exclulvely contracting with licensed contractors in /^
,met the project(See 7044,Business and Profusions Code:)The Comncteb Li- V
mom law does not apply te an owner of property who build,or improve thereon,and
who contracts fu such pmjmal with a m urscmR011censed puneant On the Conuacmis
License law.
❑tuncomp under Sm. .B&PC m ¢van
0 n v Dam
WORKER� 0 1PENSATION DECLARATION
I hareby sfilrm under penally of perjury am of Ile followi lui iarm
haw and will maintain a Cerdlicate of Content m self-ileum fa m
Worms-Comp -
bJon,u provided fm by Scotian 37M of the labor,Code.for the performance of the
work for which this permit is iuucd.
❑I ham and will maintain Worker's Compe uadon Immmance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is Issued.
My Worim s Compenatiun Insorance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need nothommplowd if the permit Is Toone hundred dollars(SIM)
or leu.)
1 unify that in the performance of me wark for which this permit is issued.I Nall not
employ any parson many marearm as m become subject olds WarWn'Canpewtion
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Ce 011010 of Esomptian,you mould
laterite$Object m the Worker's Compensation previsions of the Labor Code,you mum
.,Zforthwith comply with such provisions or this permit shail be deemed revoked.
O
Z= CONSTRUCTION LENDING AGENCY
[. 1 hammy strum IMI there h,mnsuN
unn performance agency for the performao of
�
i the work for which this permit is issued(Sec.3097,Civ.O)
WQ Undoes Nano
�
.7 z Lcnders Address
U Q I certify mar I have reed this application and sole mar the shown Information h
IL!' correct.l agree m comply with all city and musty odlnmma and sate laws relating in
Q rV" building cmawedon.and hereby authorize representatives of this city b mer upon the
IT7 ,hove-mentioned property for Inspection purposes
(We)agree m am,indemnify and keep harmless dee City of Cupertino against
w.Vl Ilabllilbon judgments,core and expense,which may in any way veme again bid City
V in
APPLICANT aN Ehe RSTANDSIhOD WILL COMPLY WljH A NON-POINT Issued by: Date
SOURC RE IATIONS.
b Re-roofs
Si o Pp is VCamO�cear I IDam
HAZARDOUS MATERIALS DISCLOS549 Type of Roof .
Will tha applicant or future Wilding mcupenumre of bua lc hazardous material
as defied by that Cupedno Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Sacdan25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yca Kll�u
7niaHWill the applicant or future building=upon,lea equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air conamtnents b dcfiud by the Bey Area Air Quality MensScmcnt all new materials for inspection.
u]Lh&SafctyC�.ScW=25505,25533vW25534.
lcG❑Yet )<NuI hemand the bamorlo�mucrieaaquimmcw underchepter6.95ofthe Califor-IuMersmM thatiftie building
cwt cu nmy haw&lenan4metIthmyrespmulnilllywmJfy de pen of me
i n whichmuatbemmpd win...0taCedOnmof c� a Signature of Applicant Date
owner ser aOtharimds ant C:i Daa All roof coverings to be Class"B"or better ('/