05040001 (3) CITY OF CUPERTINO ':'""'
BUILDING DIVISION PERMIT CONTRACTORIINFORMA.TION ,
BUILDING ADDRESS: PERMIT NO.
KALLIO CONSTRUCTION 05040001
OWNER'S NAME: PERMTT ISSUE DATE '
E: SANITARY OL NO.
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LOo LICENSED CONTRACTOR'S DECLARATION Job Description
UC I thereby affirfm Nu I am licensed under provisions of Chapter 9(commencing
Is with Section 70W) Diviai..3.f the Business and Prufessinm Code.and my license is
"_may in fonfo erode e [I] KITCHEN REMODEL G�
��Z License Cl Lic.g 55N �7C'S
n F Date Convacwr�� Td ;•-
q ARCHITECTS DECLARATION
�i to
aI understand my plans shall M used as public records /
ots 1
G Liccnsc0 professional
Oal I am exempt
form
DECLARATION LJ
0 0 1 hereby reaso affirm oat 1 1. exempt from the Contractor's Co License Law for the
OO following reason.Permit
I.
ire Business and Pmfeviotli CMC:Any City at county (�`\
m which its Iifu a permit m eunawct alcor,hn for such
demolish,fi repair any tatemn t V
F Z< prior m is issuance,also mquims the anemed Of for such permit w ice s signed statement
that witpursuanttotheofDiviomoftheo,Bus mr'sndProflaw(Chapta9 Sq.Ft. Floor Area Valu [ton
F�F e (commencings,heisxem with therefrom
and t f Divisionr or the alleged
ess and on.Any
vi Code)or
Nat he is exempt tMrtfrom and the bssu for the alleged exemption.Any violation of
Section 7031.5 by any affliction for apermit mbi.Ix the applicant w a civil pcnrhy Of 3_EiVV flJber00 Occupancy Type
not mom than five hundred dollars(SSW).
❑I,ssowner of the property,or my employees with wagesu their tole compensation,
will do the work and the structure is notimended or offered for sale(Sec.7034,Business
and Profcadons Code:The Contractors License law does not apply to an owner of Required Inspections
property who builds;orimproves thereon,and who does suchwork himselfor through his
Own employees,pmvidcd that such improvements are not intended or offered for We.IL
howevco the Wilding art improvement is sold within ane year of eompktion,the owner-
builder will have the burden of moving that M.did not Wild or improve for purpose of
sale.).
❑h as owner of the property,am exclusively emu taitig with licensed convectors to
convect the projeet(Sec.70W,Business and Profits um Codc:)M Contractor's Li.
cense law dors not apply no an owner of property who Wilds or improves;thereon,and
who contracts for such projects with a conuactor(s)licensed pursuant in the Contractors
License Law.
❑14m exempt under Sec. .B&P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury mic of the following doelarations:
IC33377aW
ham and will maintain a CeniOeam of Consent to self-insure for WorkeesCompen-
n,u provided for by Section 37M of the labor Code,for the perfmmance of the
k for which this permit is issued.
have and will maintain Workers Compatsmion Insurance,u required by Section
of the labor Code,for the performance of the work for which this permit is issued.
Workers Compeesation Insurance Cartier and policy r umMf ere:
rier. 5T44r& FVA)n Policy No.: /y 1�✓� �,
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTuscedrn need not W completed if the permit is fm one hundred dollars(SIM)
or less.)
1 certify that in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner so as In become subject to tW Workefi Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Ceeificam of Exemption,you should
become subject to the Worker's Compensation previsions of tic Labor CMC,you must
.JZ foMwi o comply with such provisions of this permit shall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
(-. I hereby arfm oat them iso eoesbuvtion lending agency for the perfurmmce of
a the work for which this permit is issued(Sec.3097.Co.C.)
W Q Lender's Name
G Lender's Addncss
U O I certify that 1 have read this application and some Net the above information is
W F' correct I agree to comply with all city and county Ordinances and sum laws miming in
O U building convection,and hereby auoorne representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
0. (We)agree to save,indemnify and keep brimless the City of Cupertino against
py liabilities,judgmens.costs and expcnsu which may in any way accmc against Mid City
U in cortsequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO)TRCE REGULATIONS. 11/O�
��- KK�f�n�3 / Re-roofs
Signature of Applicani/Conuactor drier
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building decorum.ore or handle hvardom material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Inkcede.section 25s3z(a)7
You
NO
All roofs shall be inspected prior to any roofing material being installed.
F
❑
Will oc applicant or Future building acapam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havafdous air contaminants as&I'Med by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
❑Yes CyNu
I have sad the haraNcv7s�materials requirements under Chapmr6.95 of the Califor. r
nice Health&Safety Code,Section nM5,25533 and 25534.1 undcrstard that if IM Wilding
data not Currently have a renew.that it u my rtaporrihility w nodly the occupant Of the
mgm�mcnu which muv be met priorwissuancc oh Ccrufca¢=o�r�a�e� Signature of Applicant Date
Owner aWmm�r;. asr— � l f nt
D=m All roof coverings to be Class"B"or better
c