04120080 (4) CITY OF CUPERTINO �"` zs°s%. 'm
BUILDING DIVISION PERMITCONTRACTQR�`INFORMATION
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BUILDINGADDRESS: - PERMIT N004120ID80
10305 EL PRADO WAY A
'ER'S NAME: PERMIT ISSUE DATE
ERNA JACKMAN 12 /13/2004
PHONE: - - SANITARY NO. CONTROL NO.
ARCHITFICTENGINEER: BUILDING PERMIT INFO
BLDGELER PLUMB MECH
0 0 0 0
� u00 LICENSED CONTRACTOR'S DECLARATION
w❑ I cmby affirm that I am I d under P signs of read to 9(commencing Job Description <
U withSccu Bof DthatIn3ofde BusircuaBd Bl=fccsiam Code,andmylicc is - - - -' — "-
n« in full fo an of •/ _
,„ 7 KITCHEN REMODEL
ti El Licenu lass Lie.It
=_�_o Data Contractor CONTRACTOR: HOME PROS -
' n} - AR FTG(.TSDE R ON
1 undcrwnJ y Isle sha�bE used ss Pnrsts
JyU
3,i- Licensed Professional
/O VNE ¢ DE RATION _
<q I hereby a am the un' scmpF! dte Contractors License
Law far the
z eso following mason.(Section f�,Business and Professions Code:Any city ar county
x m T which mquires a Permit to construct.alter,improve.dcmnlish.or repair any structure
't-'rs pdm w its issuance.also requires the applicant for such Permit to file a signed statement
< thashpursuant cislicensedpursuanoNmvi
cpsioosofdeConuuwLaw Sq.Ft. Floor Area Vall.1040)'714 _
ex (commencing with Section 7000)of Division 3 of the Business and Professions Cade)ser
i that he V eumpt thmefram and the baso for the alleged caunptian.Any violation of /r, a e,..
Section 7031.5 by any applicant fora permit subjects Napplicant w
e appa civil Penalty of .APN Number U ({fit �( /1 Occupancy Type -
not mom than fivelwnamddmlers(5500). 34230015 . 00 ({I)I1
❑Las ownaof Nepropeny,armye.Playtex with wagoastheiruleenmpensatiod.
will do the wart,and IW structure is not intended or offered forage(Sm.70a4,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of - RequiredInspactPns
propenywho holds orimp neathemon.and whodoessuch work himulfor through his qp
ownemployms,provided deatsuch imOwvementsare nmintandodaroffemA rorsale.If. --
however,the building or improvement is said within one year ofcompledon.the owner- - - - B11,
T1. Etl
builder will have the burden of proving Na he did nm build or improve far par s ssc of .. . . . .. .._ L11 t_,)
sale.). ( ` Jj(r5' /
I,as owner of the prolan,am exclusively contracting with licensed contractors to - �`"/ �L�CL�IjjG';` tl
cumtrucr the pmjee,(Sec.]044,Business bad Prefe ti as Code:)The Connector's U.
... .., U ll�� Vl
cause law docs not apply w an owner of propeny who Wilds or Improves Iheneon.and
who Contracts(Vr such projectawith a con=wr(s)limmedpursuaniwthe Contractors .. .. . . ..
Law.'
I em exempt under Sec. B&P C for Nis reason
er Dau
WORKERS COMPENSATION DECLARATION -
Iherebyafrn under penalty or perjury mm of be following dealarations:�
I have and will maintain a Certificate of Conserv to self-insure for Workers Compcn- -
sation,m provided for by Section POB of We labor Code.for to performance of the
work for which this permit is issued. -
1 have and will maintain Worker's Compensation Insurance,as required by Section
J]OB of Nc labor Cope,for lM performance of .work farwhich Nis permit isissueJ.
y0 iter tp rasion scan ort numhcrarc:
C Vh No.: _
E IFICA F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GTIs section decd not hecomplcmd ifthe Permit is for one hundred dollars(5108)
in less.)
1 eenifv c perfnmu of Ne work far which this Permit is issued,l shall net
cmploySYny onma u maswhecome subjauo thew iters.Compensation .. _ ..
Laws of Eflifomia aso
APPI¢a^tZ9 -
N I TO APPL f, making this Cenificata of Exemption,you should -
.JObtto a omp w4 c kcr o ompcossuon pwvit steal of the ImMx Code,you mast
foMwith comply w' Such provisions or this Permit shall be deemed rooked.
'Z" CONsrpucnON LENDING AGENCY
I hereby grime that Neu is a conswction lending agency Or the perfurmanee of
a the work fur which this permit is issued(Sec.JIN],Civ.C.)
ll.1 Q Lenders Name
G Lenders Address
az
fJ C) I certify that I have rod this application and sow Nat Ne above Information is
Ik. F correct I agree in comply with all city and county on irs noes and sure laws relating to -
C)U building construction,and hereby authorize represemztisv of this city to enter upon the
r W ahave-mentioned property for impection purposes
CL (We)agree w save,indemnify and keep harmless the City of Cupertino against
F h fianihi s,judgments,costs and expenses which may in any way accrue against said City,
tilt in consequence of the granting of this Permit
.. APPLICANT UNDERSTANDS SAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
ovac��W � Re-roofs
Signa o yCo mr -` Data
A ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or future Wilding occupant store or handle hvmdow material
m
defined by pe,Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Is,Section zssPea)?
0YGyyyyy,,aaaaa�����' All roofs shall be inspected prior to any roofing material being installed.
V
Will the i ant or future building mcu t use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
\t pp is g pan
emit heraAnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Dist it'?
[D Yes �N0
a
I have read the herrn duus materials requirements under Chapter 6.95 of the Cali fan
nig Health&Safety Code,Sections 25505,25533 and 25534.1 undcrsund thin if the building
docs not cuncm .ha.ga rcnaoe t is my responsibility w nmiry the rccupem of dm
my m "h ch m4L hll� p�norwi ansa" sed--- ancy.
/h B`�, Signature of Applicant Date
ow atha as em Dare All roof coverings to be Class "B"or better