04080042 (3) C 'FY OF CUPERTINO >#s 'd"h -'� *++b" �" '"�"",
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUB.DING ADDRESS: JERMY TUCKER AND JOYCE CH PFGRMIT No. 4080042
OWNER'S NAME: PERMIT ISSUE DATE
,TF.RMY TTTrKRR AND TOW-P. (-PA f- loonzi
E:
SANITARY O. C MROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�mz LICENSED CONTRACTOR'S DECLARATION
a C I hereby afrom Nn I am licensed under provisions of Chapter 9(commcwing Job Description
T,«Uwith Section IMP)of Division 7 of NC Bund PmfeuCuba,and my he...is
sies amlu tofmlmreoauderr"I'
7KITCHEN REMODEL (CABINETS/COUNTER TOPS,
l u, License ClazsLic.X
Z�o oath ConLracwr_ ANTI KNOCK/ELECT. OUTLETS) _ l
ry
ARCHITECTS DECLARATION
yyr w 1 understood my plans shall be used as public¢cods
7aU
ant- Liccnscd Professional
+03 OWNER-BUILDER DECLARATION
1 hereby affirm Nat 1 am exempt from the Contactors License Law for the \7
3:o o following moon.(Section]101.5,Business and Profecound,Code:Any city air county
x m alter,improve,demolish,or repair any nrvcom,
which myuircs a permit m ennswcl,
y—'^ prior to its issuance.also requires the applicant for such permit to ri le a signed statement
that he is licensed pursuant M the provisions of the Contractor's License law(CMplar 9 Sq.Ft. Floor Area Val C(59
neFG (commencing with Section)BOB)of Division 7 or the Business and Professions Cocic)or i 0 0 0
ne that he or exempt themfmm and Or bast for the alleged exemption.Any violation of
Section 7031.5 by any applicant for permit subjects the applicator o a civil PCORRY Of ApN Number Occupancy Type
not msec Nan five hundred dollars($W. r
❑ 1.a:irwor,eef the prepeny,or my employees with wages ax thdrsole compensitinn, 32637044 . 00
will do Ne work,end Ne etruaum is not intended or offered for sale(Sec.]044.Business
and Professions Code:The Contractors Liccrve Law does not apply to an owner of Required Inspections
prepeny,who buildsor improves thmapn,and who doeas ish work himself or through his
own employ=,provided that such improvements art not intended or arered for sale.If.
however,We building or improvement is sold within ane year,of completion.one owner
builder will have the bu den of moving Nal he did not build or improve for puryose of
sale.).
❑ I,as owner of We prnpeny,am exclusively contracting with licensed convectors to ,
owsttum Ne project(Sec.7044,Business and Professions Code:)The Contractor's Li-
me law dos not apply to an Owner of property who Wilds or improsss theman,and
who com uctsfor such projects with a contranar(s)licensed pursuant to the Contractor's
L ewe Law.
/I are exempt under See. ,B 6 P C for No
mazan
Wncr Dam
WORKER'�COMPE.NSATION
CLAR ON
I cwby aR,m under nally of perjury onto cfollowing declarations:
haveand will maintains Cenifica a of Consent to self-insum fur Workei sCompen-
ax Ona
for by Secran 3700 of We Vbo,Code,for the performance of the
work far which Nis pami,is issued.
❑1 have and will maintain Worker's Compensation Insuonce,az required by Section
371 of the labor Code,for the performance of the work for which this pmmit is issued.
My Worker's COmpenaunn losunnce carrier and Policy...her am:
Cam er. Policy No.: ..
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he eomptewd if the pertnil is foront hundwd dollies(SIOO)
Ices.)
I certify Nat in the performance of the work for which this permit is issued.1 shall not
employ an4A (:A-N
manncr n m Catmc sub ecuo the Work..Compensation
Laws ar C4Tf,afm g N ani cart of Excmp,ion,you shout]
rker's Compcwtion pmvisions or the Labor Code,you moa
.J O fu with comply with such pmvisinns or this purmi,shall he deemed¢vaked.
Z CONSTRUCTION LENDING AGENCY
E. 1 hereby afrrm that these its c.nawclimi lending agency fn,the performance of
ai the work for which this pcmut is issued(Sec.3097.Civ.C.)
IL7 O Lemm,'a Name
=z Land rsAdd. C—
U 0 1 certify Nat 1 have read this applicidwo aM sate the tW above information is
U. P: correct.l agree to comply with all city and county on inanaes and sole laws rclning in
0U building convection,said hereby aurhotne mpmseno,ives of this city to enter upon the
,r W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and kith hay in an the City scenic
Cupertino against
`LUN iric.i0es,judgmenkt.costsandcxpcnxfo which they in any way accrue againstsaid City
U APPLICANTeUNDERSTANDSourflui,cifNr D WILL OMPLY WITH ALL NON-POINT Issued by: DatemAo
S URCE RE LATIONS.
Re-roofs
S! azo o p t am/Con ac or Dim
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the applicant or future building Occupant stare or handle haaamous material
az dart by the Cupertino Municipal Code.Charm,9.12.and the Health and Safety
tole,Semon 2553]d)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
r
Will,he applies.,or t Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air conmminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
YCS
i have wad the Martinus materials myuircments undcrCMpmr fi.95 of the Califon
nix HW Ith k Safcy Cade.Seetion 255(15 23571 and 25334.1 understand Nat ifde Wilding
does no,cunt ul,have a moan,dim' ts my rcspo sibility to notify the a<upan,of de
recuircmcros which must Wmet p' W W., c afaccrufleatcoroc, party Signature of Applicant Date
610 1P
Ownc,n I mixedapcnr .Dat All roof coverings to be Class "B"Or better