03080117 (4) CITY OE CUPERTINO ��' sy- T"
BUILDING DIVISION PERMIT CONT==RACTOR�INF9RMATIOO N
" No ADDRESS: UTLEY NELSON V AND BARBARA 'K"""03080117
DR
-R'S NAME: PERMLT I SUE DATE
Ng; SANITARY NO. CONTROL NO,
ARCHITECI'/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
8,Z, LICENSED CONTRACTOR'S DECLARATION
u I hereby affirm thm 1 on licensed under provision of Chapmr Y(commencing Job Description
!�E with Scaion]IkRp of Divislon3orthc➢using.vantl Prufcaslam Code.andmyliccnsc is FINALE®
ifull n
j Z forceand arm"'
License Class KITCHEN REMODEL
Dam Contractor
DELL Ukg'',�
�EE ARCHITECrS DECLARATION CL 1 7 2003
1 k 1 understand my plans shall he used as public records ,
)yU
°O LiccnSCU Prolcxsianal o w .
OWNER-BUILDER DECLARATION
BUILDING
a X I hereby affirm that I am exempt from the Contractor's License Law for the �I
O O following mason.(Semon 7031.5,Business and Pm(caainns Code:Any city or county
e 8� which requires a Permit to construct,alum,improve,demolish,or repair any structure
a prier In its issuance.also requires the applicant for much Permit to Olc a signed statement
m< that he is licensed pursuant to the pmvisionnf@eCnmmcmr'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuatwn
21-Q (commencing with Section 7000)or Division Sof the Business and Prorwions Code)or
that he is exempt doorman and the basis for the alleged exemption.Any violation of 32635029 . 00
Section]031.5 by any applicant for a permit subjects the applicant o a civil penalty Of APN Number Occupancy Type
not more than five hundred dollars(S50)L
❑1,w owner of the Company,or my employees with wages as their able compensation,
will do the work,and the structure is not intended or offered for ale sec.7W.Business 101 — =DAIej(P d Inspections
and Professions Cade:The Contractor's Licenx Law does not apply to an owner of 10 2 - ,PIERS
proper who builds or improves thereon,end who doessuch work himself or through his
owncmployces,provided that such improvemenuare notintended oroffered forsale.If, 103 — UFER
however.me building or improvement is sold within one you oreompletion,the owner -
builder will have the burden of moving that he did not wild or Improve for purpose of 104 — REBAR
0"le')
as tweet of thr
e prope ,am exclusively convecting with licensed Contractors to 105 - ANCHOR BOLTS
a
0..In)
the project IS
jeec.]baa,Business and Inclusion,Code:)Toe ConvactorY u- 106 — SEWER & WATER
cense Law does not apply to an owner of property who builds or improves themun.and 202 - UNDERFLOOR PLUMBING
who contracts far such projects with a conanctons)licensed pursuant to the Contractor's
Licenaal-aw. 203 - UNDERFLOOR MECHANICAL
of mon Can pr ,Se B&PCfar this ssop
I u ' Data Z O 204 - UNDERFLOOR FRAME
'R'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby elfnd under pcnelty of perjury one nfehe following declarations: 301 — ROUGH PLUMBING
I have and will malnaln a Certificate of Consent to ser-lasum for Worker's Curdled- 302 — TUB & OR SHOWER
cation,as provided for by Section POO of the Labor Code,for me performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Inunnec,ss required by Section 304 - ROUGH ELECTRICAL
POO of the Labor Code.for me performance Cliffe wad far which this permit is Issued. - 305 — FRAME
My Worker's Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Currier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(TTuseetion need not becosoncied if the permit is for one hundred dollars(SIM) 309 - EXTERIOR LATH
I,Certify 310 - INTERIOR LATH
employ
mm in cob performance of the work for which this permit is issued,1 shall not
Law oanypcnonmanymannerseasmbewmesabjccuntheworkcnComPcmatian 311 — SCRATCH COAT
Laws of California.Dere 313 - ROOF NAIL
Appfieant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
hecame subject to the Worker's Compensation previsions of Out Labor Craft,you must
.JZ forthwith Comply with such provisions arthis permitshall he Coached mvokcd. 502 — FINAL PLUMBING ENERGY
z8 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(:. 0 IherebyalRrmthatthemisaconawctionlendingagencyl'nrtheperformanceof 504 - FINAL BUILDING ENERGY
C(i > he work for which this permit is Wood(Sec.709],Co.C.)
ip ander'aNme 505 - FINAL ELECTRICAL
z Lon aer'Add., 506 - GAS TEST
U O 1 certify mat I have read this application and save that the shove information is 507 - FINAL PLUMBING
torten.I agree to comply with all city and county ordinances and state laws relating to
�U building construction,and hereby authbriae represenutivct of mis city to curer upon the FIN MECHAN CAL
} U above-mentioned prefer for inpection purposes.
F+
(we)egrte m arc,indemnify and trcp harmless the City of Cupertino against 0 9 FIN
h inConseqjudgments,cosuangofmisseswhichmeyinanywyacrnrcagamstwidCity 5 A NG
UvZ in Consequence judg ethe grunting u(thispermit.
'—' APPLICANT +R AND AND WILL COMPLY WITH ALL NON-PPOINT Issued by:5 WORKS Date - Z 3 oE
S`0 2 '_ _ t- g�7z/o 3 Re-roofs 07
g a re of 1G°HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future wilding occupant stare or handle hatmous material
def bell bythe Cupertino Municipal Code.Chapmr 9.12,and the Health and Safety
Section 253P(ap /
❑Yea All roofs shall be inspected prior to any roofing material being installed,
Will the applicant or forum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air cobtaminanu as tkGned by be Day Area Air Quality Management all new materials for inspection.
Ontario,? ��/
❑Yes Lunt
1 have read the harandousmamrials mquiremenu under .Chapmr 6.95 of me Califon
ilia HCulth&SofcayC Sccuunx 25XI5,335JJond 355Ja.l undersand thatifthc building
docs�Wa<rt`i{pnffj of pant, at it it my res nsihiloy m mm y me occupsm of the
rt mooned must in Hotn, u racertifmamofsea r. Signature of Applicant Date -
crura thoriveJegem All roof coverings to be Class "B" or better