04020146 (3) CITY OF CUPEWrINO
BUILDING DIVISION PERMIT CONTRACTORINFO'RMATION
BUILDING ADDRESS: PERMIT"04020146
OWNER'S NAME: PERMITISSUEDATE
01 JACK & TR
NF: SANITARY ND. CONTROL NO.
ARCHTTE-CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�0z LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
vo with5ection] )refUi,iii,m3ofthe up sipTssand Professions Codc.antl mylicensc is
o. In rut m d_freer. xJ 06 y BATHROOM REMODEL
5 jJE License a Le.p
ZDam z G' t RATION 1 CONTRACTOR: KOBETSHKY CONSTRUCTION
ARCHITECTS
u und39y
up} he scdaspuhlic rccards
Dyc
u F L
3 a,1-i Licensed Pmfcssional
s' 3 OWNEIKUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Pmfesamas Code:Any city or county
X m which requires a permit to construct,alter.improve.demolish,or repair any structure
w—te prior o its issuance,also requires the applicant for such permit to fie a signed statement
that he is licensed pursuant to the provisions of the Comment's License Law(Chapter 9 Sq.Ft. Floor Area Valul 000
QHS (commencing with Section 7000)of Division 3 of the Business and Professions Code)at
Y
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of APN Number Occupancy Type
not more than five hundred dollars MOB.
❑1,of owner of the property,or my employees with wages as their sole compensation, 34245005 . 00
will do the work,and me structure is not intended or offered for sale(Sec.7044,Business
and ProTh
Professions Code: e Contractor's License Law it=not apply to an owner of Required Inspections
property who builds or improves Whom,and who doessuchwmkhimxlf or through his
own employees.provided that such improvemeou...I intended oroRered tarsal..ll,
however,fee building or improvement is sold within can year of completion,the owner- /
builder will have the burden or proving that he did not build or improve for purpose of
salnJ. 0
❑I,as owner of me propeny,am exclusively concocting with licensed connection n
cone La the project(Sec.](44,owner
or and Professions Code:)The Contractor's Ll-
c c law ones not apply i,an owner of property who sed p or improves thneon,and
who common;far such pmjecu wish a contractor(s)licensed pursuant(o the Canmctar's
LieI am Lew.
1 am exempt under Sec. .B&P C for shis rcuon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afftm under penalty of perjury,one of the following declarations:
have and will maintain a Cenifcam of Consent o self-insure for Workers Camper.
steip
n,as divided for by Section 37W of me labor Code.for me performance of the
walk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
3]M of me Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseclion fired not Wcompleted if the permit isforonc hundred dollars($1 00)
Icsa)
I cenify the'in me fn ee of the work for which this permit is issued,l shall not
employ any 9soni�aBnrxresuhject mthe Workcrs'Cnmpcnsatlon
Laws IC
Applicant
TO APPLICANT:IL a making this Cenifcam of Exemption,you should
c c s
Muhjen n she Worker's ompcoamion provisions of me Labor Code,you mus(
,JO forthwith comply with such provisions or this permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
'rt 14 thereby aflion that there is a construction lending agency for the Performance mf
> the work fur which this permit is issued(Sec.3097,Civ.C.)
W Q Lender'a Name
Da Lender's Address
V 0 I certify that I have read Oils application and sum me(the shove information is
(L t..t correct l agree to comply with all city and county ordinances and sum laws rcla(ing to
O V building convection,and hereby rut.nix representatives of this city so enter open the
U ahovcmcn(ionad property for inspection purposes.
gya (We)acme to save,indemnify and keep harmless the City of Cupertino against
to
liabilities Judgments.costs and expenses which may in any way accrue against said Cfly
C)z his Permit.
APPL CANTSTANDS
eUNDERof the granting Of tAND WILL COMPLY WITH ALL NON-POINT Issued by: Dall5?/Wo' eq
fa
EG_ULATIO
Re-roofs
ater.ofAPPImaH Co
GUS
MATERIALS DISCLOSURE or I Dam Type of Roof
Will fee applicant or furore building occupant store or handle horrendous material
ef reed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
e.Section 25532(a)? �/ All roofs shall be inspected prior to any roofing material being installed.
❑Yes 6d Na
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
(havnrdous air contamina�Tafcnid
as defined by the Bay Arca Air Quality Management all new materials for inspection.
rsuict?
❑Yes No
[have mail
the s rcyuimmcnu under Chapter 6.95 of the Cali(ury
nia Flcahh&Safc(yCodc,S_cuons25505,25533 nd25534.Iundcamnd thmiftme building
does not currently have a tenant,met it is my responsibility to notify the occupant of me
requircheentswhichmuft porto issuance ors CcnifcateofOccupan.. Signature of Applicant Date
z
I net ter authorized arc oat_ All roof coverings to be Class "B" or better