05070073 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC�`T(IRINEORMATION ':
.r v =3AR -.,
BUILDING ADDRESS: A-1—DESIGNS PERMITNO.V 5 0 7 0 0 7 3
7859 CRE L
OWNER'S NAME: PERMITISSUE DATE
LEE, DENNIS 426 RAYNOLDS CIRCLE QI/13 /2005
_ ,NE: SANITARY NO, CONTROL NO.
(408) 573-7478
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
°00 LICENSED CONTRACTOR'S DECLARATION Job Description
'i u F 1 hereby affirm duet 1 am licensed under provisions or Chapter 9(commencing P
i`uf with Section 7")of Division 3 of Ne Business and Professions Code,and my license is
n=� in full fora and cff
Dyz uahme t �" Lic. SS�,�ZS KITCHEN REMODEL'�AND ELECTRI SERVICE UPGRADE
i r p Dam (°j1� A Carreto(A\ nFb�A1S
/ s ARCHITECTS DECLARATION sd VYli 'uL C.m
? 1 understand my plans shall W used as public annual
u GLicensed Professional
..05 OWNER-BUILDER DECLARATION
iY 1 hereby affirm that 1 am exempt form the Common's License Law for the
00 following reason.(Section 71D 1.5,Business and Professions Code:Any city or county ]
$ which m4uims a Permit to convect,alder,improve,demolish.or rean
pair y structure eture _ , ()
Fi< prior us its issuance.also requires doe applicant for such permit to rile a signed statement
mm that he is licensed pursuant to the provisions of ftCOetewnLicvclsw(Chhapter9 Sq.Ft. FloorlAiea o p L'acisL1 �f'0 V� Valuation
CFO
W52 (COMM(eommeneingwith Scctlon7f100)ofDivuion3ofthc Businusand Professions Codc)or
chat he is seem,,therefrom and Ne l ssu for the alleged eaampti.a.Any violation of
Section 7031.5 by any applicant for a permit subjttu the applicant w a civil penalty ofeA 0 Occupancy
not more than five hundred dollars($W. P Y Type
❑1,ot owner of the,roomy,or i...
employees with urges,their acre compens t.
will Pr the woes and th....wrt is not intended or a w de Tomato(Sec.7064,Business
and arlywh ons ldsor Therms the
wn cave Law docs net apply tom owner of Required Inspections
own eny who D,itis or i m proves thereon,and who as n soh wank himself her Nmugh use
own employ=,the
ing or i that such impmwmenu are not ear dedcdc oroQetW forlife O e.If.
M1uilder .due Wil dingorimpmwmennissoldwithinane year of completion,Ne owned
builder will have the burden of,musing that he aid not Wild or improve for purpose of
sale.).
❑1,as owner of Ne property,am esclusively convecting with licensed Convectors to
covwe,the project(Sec.7064.Business and Professions Code:)The Contractor's L-
ceese law don not apply As an owner of property who Wilds or imporwx domain.tad,
who contracts for such projects;with a contrecwr(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. ,B&PC for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
40 1 hereby aim under pcnahy of perjury one of the following declarations:
1 have and will mainucina Ce r$MMof CC=nllrself-insureforWorkersCompen-
.fit..as provided far by Section 3700 of the labor Cock,for Ne peHmmma of Ne
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the LAW,Code,for the performance of the wort for which this permit is issued.
My Workers Compensation Insurance caricr and Policy number am
Cartier. T[.)KD Policy No.:
ja439�V-zm+
CERTIFIC TE OF
OMPESATION INSURAN WORKERS' '
COMPENSATION INSURANCE ,
(This smism head tat W completed Rthe Pundit its Finance hundred dollars(SIM)
ar less)
1 ccrfy that in the performance of the work for which this permit is issued.I shall at
employ any person in any manner an as an become subject to the Workers'Comp roauon
laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making tau Cenificaw of Exemption,you should
become subject to the Wohc's Compensation provisions of the La Wr Code,you most
.Jz forthwith comply with such provisions or this permit shall he decreed revoked.
z O CONSTRUCTION LENDING AGENCY
rt•+� I hereby affirm chat thera is a covtrucuna lending agemy for the performance of
!Yi ? Ne work for which toil permit is issued(Sec.3097,Civ.C.)
�W Q Icndces Name
z fender's Addmao
U O 1 certify thn I have read this application and such,that the show information is ,
(•' carom 1 agree to comply with all city and county on inmas and sum laws relating to
0U Wilding convection,and hereby authoma aprcateades of this city to enter upon the
r W above-mentioned properly for impaction purposes.
LL (We)agree m saw,indemnify and keep harmless the City of Cupertino."in"
f'fq
liabilities,judgments,costs and Caperton which may in my way accrue against mud City
,)
U in cmuaacqucna of the granting of this pertnis
^ APPLICANT TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
/ 5 URCE T
Re-roofs
\ Shgan o Ire UConvmwr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser future building occupant atom or handle havardous material
As defined by the Cupertino Municipal Critic,Chapter 9.11.and the Health and Safety
Code.Section 35532(.)? All roofs shall be inspected prior[o an roofing material beim
❑tio ; glad P P Y g g installed.
Will the
us applicant or future building by the B use equipment her Micas which
If a roof is installed without firs[obtaining an inspection,I agree to remove
emit harardnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Distrin?
❑Yes [;DW
i
I have moa the huaNdms materials¢quirements under Chapter 6.95 of Ne Cable,
.is He.lth&Safety Code.Sauov25505.15533 and 25534.1 understand We if tae Wilding
does not Curren haw tenant.Nat it u my m&Wmihilidy w nndly the mcupmt of Ne
re thermals met Poor to issuance or a cercricsm or Occupancy. Signature of Applicant Dale
wneron o r dAgent Date
/ All roof coverings to be Class "B"or better