03120102CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUB-DINCADDREss: -
DONATELLI CASTILLO BUILDERSERMITNO03120102
OWNER'S NAME:
PERMr[IssUE DATE -
E:
(408) 287-4RRf;
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECr PLUMB MECH
I� t� E 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
With Sermon 7") of Division Sof NC Bus' ess and Professions Code,mdl my hear. is
in In0lSr,ederfee d
Llccn��rasa [
KITCHEN REMODEL -
Date _ Can sur ,b
W1
FINALE
�OL��
ARCHITECTS DE
QatonticI
tangy J my �la� s l,hc . rc
MAR 3 0 2004
Libenscd Pressor r�>u as
OWNER-BUILDER DECLARATION
I hereby affirm that I o exempt from the Contractor's License Lew far the
following reason. (Section 7031.5 Bte iness and Professions Code: Any city m county
which requires a permit to construct, alter, improve, demolish. ar repair any structure
e nnn
prior In its issuance. also requires the applicant for such Permit Ne a signed statement
that he is licensed puru
mano the provisions or the Contractor's License Lov(Chapter 9
Sq. FL Floor Area
a uation
(commencing with Section 7") of Division 3 of the Business and Professions Coal or
Nm therefrom and is exempt therefroand the basis for the alleged exemption. Any violat)on of
Section 7031.5 by any applicant for a Permit subjects Lou eppliemt to a civil penalty of
3 9VV1TV1bgr0 O
Occupancy rfype
net moe Nan five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages or their sole compensation,
will do the work, and Ne srsucture is not intended or offered for sale (Sec. 7044, Business
and Fiction... Code: The Conuacura License Law does not apply to an owner of
Required Inspections -
property who buildsor improves thereon, and who doessuch work himself or Otrough his
own employees, provided thatench improvements are not intended or offered formic. If.
however, me building or improvement is sold within ane year Of completion, are owner.
builder will have the burden of proving that he did not build or improve for purpose of
aa]a )
❑ 1, as Owner Of fee property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Communes Lt.
come Law does not apply to an owner of proWdy who builds or improves themun, and
who contracts for such projects wish a contortionist licensed pursuant to Ne Comraearr's
License Law.
❑ I am exempt under Sec. , B,Y P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby a0im under penalty of perjury ane of the fallowing ammunitions:
have and will maintain a Certificate of Consent to self-insum for Worker's Compen.
radon, as Provided for by Section 37M of the Lwbm Code. far Lou psommmnm of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, m required by section
3700 of NC Labor Code, for the performance of the work for which this permit is issued.
-
MyWork kC miw ¢alio Insurancecamicr and numberam:
-
gPolicy
ame. x
C`
A CERTIFI ATFEXEMpI'1QY�17 4\ OR
Q"' COM ENSATION INSURANCE
(This aecarra mcd not he completed If the permit is foram hundred dollars ($100)
or less.)
1 cenify Nal in the pe,rom ace N the work for which this Permit is issued, I Nall not
employ any person in any manner an as to become subject o the Workeri Compensa ion
Lawa of California. Dam
Applicant
NOTICE TO APPLICANT: If. after making this Comficam of Exemption, yoo should
become subject u the Worker's Compensation previsions of Ne Labor Cade, you most
fonhwish comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby am Nu Nem
1Eris s construction lending agency I'm the Performance of
Ne work for which this W volt is issued (Sec 3097, Civ. C.)
Under's Name
a f
Lender's Address
I certify that 1 have read this application and sum that Ne Slats information is
'
correct. ]agree to comply with all city and county ordinances and sum laws relating to
building construction, and hereby aalhofln representatives of this city to enter upon the
far
arr.
pe
shove-ms,judgm propertycosts
(We) agree to save, indemnify and keep harmless the City of Cupertino against
a
iia and expenses which m
exWmeawhich may in any way accme against said City
consequence ftheSstsand
of shegrantingof this permit.
A
APP (CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
F,IC NT
ll/
Issued by: Date
SOU CERA^U{Lt1TIONS.
Type Of ROOF
�
194
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rgmu ofA Ii.aVCml1mLOData
HAZARDOUS MATERIALS DISCLO
Will are applicant or future building occupant store or handle havardoua material
definctl by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
cads, section 2553260?All
Yes No
roofs shall be inspected prior to any roofing material being installed.
j
If a roof is installed without first obtaining an inspection, I agree to
Will the applicant o roe m building occupant use equipment or devices which
remove
hazardous air contaminants as dcfincd by the Bay Area Air Quality Management
all new materials for Inspection.
bier,
❑Yes Nu
I hawmadanor. ousmamrials reyuiremcnts troller Chapter 6.95ofNcCalifnr-
maHmlNASafctyCmm,Sc .2n 5255(15,25533md25534.1undcmu^d NuifNchuildi^g
dma mol cumnlly have a tenant Nm it is my resWnsihiliry m nouly the mcuPms of Nc
re Creme 7hmostbe tpoor to o(acerdrwmorOcaupaney.
Signature of Applicant Date '
w
All roof coverings to be Class "B" or better
rorauNori'rcd ag Data