04080139 (4)CI
f PERTVo
T.,,pCC�TPERMIT
emoc DIVISION
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BUILDING ADDRESS:
KITCHENS BY MEYER
PERMIT NO.
04080139
OWNER'S NAME:
PERMITLSSUEDATE
E:
SANITARY OL N0.
ARCHITECTMNGINEER:
BUILDING PERMIT INFO
BLOC ELECT PLUMB MEC"
0 0
LICENSED CONTRACTOR'S DECLARATION
Job De !1 O
AUAJ
1 hereby affirm that l am limnwd under p!oymona of Chapmr 9 (commencing
with Section 7000).(Division 3.(the Buaineaa agCProfessioni Code, and my license is
DataI�ndef�Lic.p`/�3o�!'/
KITCHEN REMODEL NOV I6 2004
Data Conwant
AR HOECTS DECLAR N
1 understood my plans shall W used as public records
BUILDING
LllCnaLd PNfG61..aI
OWNER -BUILDER DECLARATION
I Withy affirm Nat I am exempt from donConnadors License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a Permit m construct, alter. improve, demolish, or repair any slmclum
prior m its issuance, also requites; the applicant for such permit to rile a signed statement
Sq.Ft. Floor Area
Valu ttion
that he is licensed pursuant to the provisions of the Contoncoms License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and limitations Code)or
-
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 MI3117er 0 0
Occupancy Type
Section 7031.5 by any applicant fee a permit Subjects the applicant to a civil penalty of
not mom than five hundred dollen (SSW).
❑ I, m owner of the property, or my employees with wages as thenmle compensation,
Required Inspections
will do the work end theatrudure is..timm.ded oro0ercd forsale (Scc.7W. Busirvss
and Professions Codes: The Contractors License law does not apply in an owner of
-
property who builds or impronia thereen, and who does s uch work himsel f or through his
awn employees, provided Nat such Improvements are not intended oroRered for sale. If,
however, the building or improvement Is mid within one year of completion, the owner -
builder will have the human of proving that be did not Wild or improve for purpose of
isle.).
❑ 1, as owner of the property, am exclusively connecting with licensed contractor to
eonstmet the project (Sec. 7004, Business and Profesrions Code:) The Contri Lt.
come law does not apply to an owner of property who Wilda or improves themon, red,
,
who contracts for such projects with a commicmr(s) licensed pursuant b the Contractor!
Licence Law.
❑ I am exempt under Sec. . B A, P C far this memo
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury can of the following declarations.
have and will maintain 4Certificau ulceration m self-imu a for Worker's Compere
n, as provided for by Section 3700 of the labor Code. for the peifmmance of the
work for which this Permit is bound.
❑ 1 have and will maintain Workers Compensation Insurance, ss mquimd by Section
J700 of eLabor Code, for the Performance of the work for which this Permit is issued.
W rM1 nm nation Insurance carrier and Pa nu bort art•:
r'er.
NT /Yens Policy -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notal completed if the pamil isfuronehundred dollars ($10111
in leas.)
I certify that in Ne performance of the work for which this permit is issued, I shall not
employ any pCremn In any marncrea at in become subject to the WorkCi eampcmaBom
Laws of California- Dow
Applicant
NOTICE TO APPLICANT: IL mer making this Certificate of Exemption, you should
become subject m the Workers Cme,xi action provisions of the Labor Codc, you must
foMwidi comply with such proviso. or this Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hedhy aliirm that domei; a comWnme lending agency for the Performance of
the work (car which this permit is issued (See 3097, Civ. CJ
Lenders Name
lender's Address
I certify Net I have mad Nis application and sate Nat the above information is
correct. I agree 10 comply with all city and county eminences and state taws misting to
building construction. and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wes) agree to save, indemnify and keep handle. the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDE TAN S A WILL COMPLY Wr{1i�1LL NON -POINT
SOUR EGUL
Issued by: Dale
Re -roofs
t)/7
t atom of Appli nV nnaetor arc
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building mcupanlsmre at handle havardws material
a defined by the Cupenino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes (k o
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hccent.us air contaminants a defined by the Bay Arca Air Quality Management
all new materials for inspection.
r11IC17
Al.
C1 Yes
I have real the harmnus notterialswquiwments under Chapter G95 of the Caldor.
nia Hcaith & Safcly Cede, Sectio. 25505.25533 and 25534.1 undcru nd l eadice Wilding
does not currently have a wnenr, that it i Y. matichty m notify tW .upent a the
requirements ichms) in or i u eafaCcmficaw =spm=r.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owm/�r amborizcd agent Dates