05030095 (3) CITY OF CUPERTINO •^ �,
BUILDING DIVISION PERMIT CONTRAGT®R INFORMATION ��
BUILDING ADDRESS: h PERMIT NO 05030095
OWNER'S NAME: PERMIT ISSUE DATE
SAMAR LIVING TRUST
ONE: SANITARY KCr 'CiINIMOL.NO.
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+O+oo LICENSED CONTRACT'OR'S DECLARATION f'r O O O
1 bemby aft that I am liceecd under provisions of Chapter 9(commencing Job Description
wimseatim7")ofoiwsion5ofine Businessand Nofessiom Cmaandmyucm Is ����'/,
jZ. in full Imes,mande,Hecl KITCHEN REMODEL
�? License Class Lk.a
4`0 Dam Commem, 4
ARCHITECTS DECLARATION y
?w U 1 understand my plans shall he used as public..& , G3
u.
f�e�
Licensed PmIfersi...
y OWNER-BUILDER DECLARATION `:J
l/ 1)U
<f 1 hereby affirm that I am exempt from dm Contractor's License Law for the U t
i
00 following mason.(Section 703 1.5,Business and Pro@ss3om Code:Any city at county
which mquims a permit to construct.alter,improve,demolish,or repair any stntewte
prior to its issuance,also requires IW applicant for such permit to file a signed sutemcnt
thathe is licensed pursuant to the provisions of Ne,Common's license,Law(Chapter 9 Sq Ft. Floor Area -- Valuatlon
a(�$ (commencing wish Section]I)(IB)of Division of Ne Business and Professions Code)or
it _ that he 4 exempt therefrom and the bedis fm the alleged emmp,ims.Any violation of
Samoa 7031.5 any applicant for a perlSubjects the applicant to a civil penalty of
not mom han five hundred Lao). 3 0 Occu ane Type
1,at owns of the property,or my employees with wegu as their able compensation.
will do the wart,and Ne,strumure is not intended or offered for sale(Sec.7(14,Bird...
and Prooushom Code:The Conuaomes Lione,hew doe net pply to an owner of Required Inspections
property wive builds or improves thermorind who does such work hinn.6ftudomgh his
own employees,provided that such improvements arc not intended mustered fmsale.IL
however,the building or impmvemem is sold within one year of comphoon,she owoer.
builder will have the Wohm of proving that he did nut build err improve for purpose of
salt.).
I,as owoer of she property,am exclusively conors with licensed cantr cmrs to
onswct the project(Sec.7004,Business and Pmfesdom Code:)The Contractor's Li.
cane,Law does not apply in an manor of property who Wilds or improves themon.and
who contracts for such projects with a comou tar(s)licensed p...a,in she Comnmar's
License Law.
❑1 am exempt under Sec. B&P C for Nis mason
owner lrih l 541clr : Date 1-4-0S
WORKER COMPENSATION DECLARATION
1 hereby afar under penalty of perjury ore of the fallowing declaratituns:
have and will maintain a Corti etar iscoment to ulf.insumfor WerecesCompen-
,as pmvlde,d for by Section 3700 of the Iatnr Code,for the perforame of the
for which this petit is issued
❑1 have and will maintain Worktrs Compensation Insurance,as required by Section
3700 of she,labor Code,for the performance of the were for which thus permit is issmd.
My Workers Compsnntian Insurance carrier and Policy number arc:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fliissecuon recd not beeomplemd if the .it is fortune hundred dollars(SIM)
or less.)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner ab as m become mbjal m the Wmkeri Compemation
LAppli aws of California.Wm j_/{ T�
NOTICE To APPLICANT:Ir.after muffing this Certificate of Escmption,you should
become subject in the Worker's Compensation provisions of the labor Code,you mita
.,O foMwith comply wish such provision or this permit shall he deemed mmked.
Z y CONSTRUCTION LENDING AGENCY
PI hereby affirm that there is a comWction lending agency for the pefommba of
a> she work for which this peril is issoed(Sec.3097,Civ.C.)
Q Lender's Name
a z lenders Addmss
U0 1 comfy Nat 1 have mad this application and sit¢Net the moms inforadon is
LL F correct.I agree Id comply with all city and county oNinaae,s and mule laws relating in
DU Wilding comwction,and hereby amhoda mpmxnutimes of this city to enter upon the
Na
Oom-mentioned
protins.cotyfori capeuon purposes.
(We,)agree w sate,indemnify and tett,harks the City of Cupertino against
Hz habilsocoiomposudg,of she
muand of this permit.
may in any way ammo against said City
U z A APPLICANT
ofthegranting of this pe tit.
^ APPLICANT UNDERSTADS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER ULATION
'� - � - -3-4-0� Re-roofs
Signature 01 Ascam/Conlracmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant store or handle havArEous mamnai
as defined by the Cupertino Municipal Code.Chapter 9.12,and she Health and Safety
Cat,Sccum 25532(.)7
❑Yes INu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant on,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II bra m.air cmnuminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
icR
❑secs `1*
1 have mal she hmsubkonmmol-Il wl.immenu under Chapter 6.95 of the Califor-
niaHealth&Safety Code,.Sccuom25505.25533and25534.1un&c dlhaifthc Wilding
docs Out currently ha e a tenant that it u my reayomibility w notify Ne oecvPant of the
roquir,j; yhhol, to
poor m ismanceofa Ceniucam of Occupancy.
,IP.�Jh� 3 y Signature of Applicant Date
Owner err as ori,=d senor D„t All roof coverings to be Class"B”or better