03060174 (3) CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION x':
eulL INGADDRESS: CLEAR OAK DESIGNS PERMIT ND03060174
461 MARY -AAT
OWNER'S NAME: 1723 B ROGERS AVE PERMIT issue DATE
E' (408) 436-5448 En
ARYNO. CONTROL NO.
7ARCHITECT/ENGINEER; / BUILDING PERMIT INFO
ELECT PLUMB MECH
t 0
lLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencinge5ccIkm7 ofDivim.m3ofNCB�usineb*ndProf ,ionsCo ,andmylicenwis `ena � � KITCHEN REMODEL/ELECTN_AL UPGRADE
CunutorukilARCHITECTS RA?ON
C 1 understand my plans shall be uacd blit rccunds
Jtu
k O Z', Licensed Professional
S OWNER-BUILDER DECLARATION
a I 1 hereby affirm that 1 am exempt fru.the Contractors Utica!c Lew Fl—
lar the -
p o follnwi.g mason.(Section 7031.5,Business and Pndcasinns Code:Any city ar county
ECO
4m( which rcquiro,a p.mit m corgi act,alter,improve,dcmoliab,fir repair any,..action: *�.yr p, ,r 1 1. t' I{ NWSC.�_s.^I
;y prior m its issumcc.also requires the applicant for such permit m file a signed smement
< tbmheiarcensedpursuant to the provisions nnheContractarauecomLaw(chapter 9 Sq Ft. Floor Area I Valuation
9 (commencing with Section 7")of Division 3.f the Business and Professions Q.k7 ser a I I'. 4
y Nat M Ice esempl Ncrefrom and the basis far On alleged exemption.Any viola0oa of 2 5 0 7 3 . 0
Section 7031,3 by any applicant for a permit subject the applicant to a civil penalty or AT4,ANumbe Occupancy Type
out more than five hundred dona.(SS0M. P Y YP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do Be work,and Bari g OCLUM is not intended oroRered for sale(Sec.7Daa,Business 101 — dIDS aOPS
and Professions Code:The Comment's License Law dors not apply to an owner of 102 — PIERS P
li
property who builds or improves thereon,and who does such work himself or through his
awn employees,provided that such improvement an,not intended proffered formic.If, 103 — UFER
hmveveo Ne building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Nat he did not build or improve for purpose of 104 - REBAR
gale.). 105 -, ANCHOR BOLTS
❑h u owner of dm pec.704 am exclusively confessions with licensedcontractorsR
comwctthe
es not pplyto0aa,Business and ProfessionsCode;)or
tro Contractors Li 106 — SEWER & WATER
coact'svd.ear such an owner aofproperty who
red purrimtroves the Comon,and 202 — UNDERFLOOR PLUMBING
who c.noact for such project with a contractor(a)licensed pursuant d¢Confmclora '
Lieen..Law. 203 - UNDERFLOOR MECHANICAL
❑1 am exempt under Sec. ,B h P C for this mason
204 - UNDERFLOOR FRAME
Jor W'ORKER'S COMPENSATION DECLARATION Data
205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury ane of the following declarations: 301 — ROUGH PLUMBING
haveandwillmaintainaCenificaleofConsenttoself-Insure for WorkersCrmper- 302 - TUB & OR SHOWER
,as provided for by Section 37M of Ne labor Code,for the peRormance of the 3 03 - ROUGH MECHANICAL
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Senion 3 04 - ROUGH ELECTRICAL
of Ne Labor Code,for Ne performance of the work for which this permit is issued. 3 O5 — FRAME
orkers CompeM1Noun Insurance carrier and Policy numbers 306 — HOLDOWNS
er: CERTIFI�PION 4 DRKERs• 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
rrnlsarnimrneed mode oomplcmd robe perming for one handled dollars r$IW)
nrlam.7 309 - EXTERIOR LATH
1 cenif mat in the Performance of the work for which this 310 - INTERIOR LATH
y pe permit is Issued,1 shell not
employ any person many mortician azit)become subject to the Workers'Compcnaatlon 311 — SCRATCH COAT
Lama of California,Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.aBcr making this Certificate of Eacreption,you should 501 - FINAL ELECTRICAL ENERGY
become subject t.the Worker's C.mpensarion provisions of the Labor Code,you mus
.J z Rnhwith comply with each provisions orthis Permit shall Mcleared.vokcd. 502 — FINAL PLUMBING ENERGY
z o CONSTRUCfIONLENDINGAGENCY 503 - FINAL MECHANICAL ENERGY
Ihereby.Mr.C2`12is a construction lending agency for the performance of 504 - FINAL BUILDING ENERGY
C
are work for which this permit Bissucd(Seco 3097,Civ.C.) 505 - FINAL ELECTRICAL
W� Q Lend
z Lenders Name arsAddreas 506 - GAS TEST.
U O 1 certify mat I have read this...licinkm end sato that the above information is 507 - FINAL PLUMBING
ly correct.I agree to comply with all city and county ordinances and suite laws relating m
building construction,and hereby aufhodu representatives of this city R enter upon do
O W shwa-mead ned property for inspection purposes. FIN 1_a MEC CAL
17. (We)agree to save,indemnify and keep harmless the City of Cupertino against 09 FI
ray h liabilities,judgment,cost and expenses which may in any way accrue against said City 5 I NG
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date
SOU�C�j R�sULATIOq�S._ ,,
S `i�4 1."- 0. 0 D'alow2 1 Re-roofs
Si naRrc of Applicant/Contrsemr Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building Occupant stem or handle hawdo s material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
.d0.Section 3....(.)? All roofs shall be inspected prior to an roofing material bei.
❑Yeas p p Y g g installed.
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
7niaHeaUffiSgetyCo .Sec6om25Y)S25533ad25534.lun&mmd�atifthe
hamobous air crew.. t as defined by the Bay Area Air Quality Management all new materials for inspection.
on?
❑Yes No
\
Iha e ia�smquimmentundcrChapte6 fNe WildingemadhoutdoursterialremntsunrCh .95orhe buildingnot currently haw a renan,Nat it is my responsibility to modify the occupant of me awnccignature of Applicant ate
N fl tnku(
Owner or authorized astir, D„p All roof coverings to be Class"B”or better