04050074 (2) 77
CITY OF CUPERTINO r-�?_" " `
BUILDING DIVISION PERMIT COIRAC=TOR TNk'URM'ATIUN
suaDINGADDRESS: SARATOGA KITCHEN & BATH PERMIT"°04'050074
OWNER'S NAME: PERMIT ISSUE DATE
GEORGE
E: SANITARY NO. CONTROL NO.
(408) 281-9250
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0 0 0 0
�IGZp LICENSED CONTRACT'OR'S DECLARATION lob Description
V 1 hereby.farm that 1 am licensed under provisions of Chapter 9(commencing
with Section]Olg))of Diviaion Sof Ne Businessand Professions Co ,andmylicenseis
mrean
11foederrect -?kt3, 0 BATHROOM REMODEL
$ Licenu CI Lie.p
i t;, Dem Contractor
9 ARC CPS DECLARATION ,n
1 understand my plain be use,L,Wpuh is rcanrds
OaU O //�e ralcV✓✓"G'i
C Licensed Pmfcssmoal I
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Committees Licenu Lew for the
EVfollowing mason.(Section](131.5,Business and Profession Code:Any city or county
which requires a Noweit to construct alcor.improve,demalah,or repair any structure
FSS:^ prior mire issuance.else requite the applicant for such permit to flit a signeimmement
xo lhatheislicenudPunuenuntheprovisnmoftheConector.Lietweeaw(Chapter9 Sq.Ft.Floor Area Valuation
�$ (commencing with Section]000)of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 9WN9,0"er0 0 Occupancy Type
not mom Nan five hundred dollars($5007.
❑I,as owner ofths property.or my employees with wages as therfame blamo an,
willdo the work,and the structure Isnot intended oroQered forsale(Sec.7044,Business
and Professions Cade:TO Conuutors License Law tion or apply to an owner of Required Inspections
property who builds or ire proves Nemon,and who does such wark himul f per through his
own employees.provided that such improvements arc notintended oroQered forsale.If,
however.the building or improvement is said within one year of completion,the owner
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
0 1,as owner of the property,am exclnively contracting with licensed contractors to 1
construct the project(Sec.70".Business and Professions Code:)The Comosc ors Li. t
come law dos not apply to an owner of property who builds or improves ffiewoun,and j
who contracts for ah projesn with aconusamr(q licensed pumm Co
uentOn Conuanh
o _ V
Licenu law.
I am exempt under See. .B&P C for Nis moon
Owner D.m
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations: / f -
haysandwiilnothro e a Certificate of Consent,self-insure for Worker's Cowper. [/ 1
lclo�
as provided for by Section 3]00 of the Labor Code.far Ote parfmmmce of the
for which this permit is issued.have and will maintain Worker.Compensation Insumnm,ss required by Section
of the lobar Code,for Ne perfarmance of the work for which Nis permit is issued.
Worker Come eIJ Insumntt certicr and Policy nmhcr sin:er:�CAM"TEXEMPTIONa- - iieyNa.: i393y
C TIFICATE OF FROM WORKERS'
COMPENSATION INSURANCE
(This section bond notbecompleted if the permit Is forme,hundred dollars($100)
or less.) ,
1 minify that in the performance of the work for which this permit is Wood,I shall not
employ any person in my manner an as to become subject to rhe Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject in the Worker's Compensation previsions of the labor Crum,you must
,J Q shall forthwith comply with such provision or this Permit all M dimmed invoked.
r rAtCONSTRUCTION LENDING AGENCY
[-, Ihereby affirm that them is a convection lending agency far the performance of
!�7 the work for which this permit is issued(Sec.3097.Cl,C.)
QLenders Name
r7 z Lender's Address
V O I cartify that I have mad Nis application end sum Nat the above let...it.is
conecL I agree to comply with all city and county on inarms and mare laws relating to
O t> building construction,and hereby amhorim representatives of this city to enter upon nee
H7 above-mentioned Property for impaction purposes.
Da (We)acme in ova,indemnify and keep harmless the City of Cupertino against
,-y fA liabilities,Judgments,casts and cannon which may in any way acme against mid City
Uz in conuganee of me granting of this Permit i
r APPLICANT UN TANDS D COMP WITS ALL NON-POINT Issued by: Date"
SOURCEREGU ONS! S/.-f'y
(/ry Re-roofs
Signature of Applican✓Coneacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant per future building occupant store or handle ha andous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cade,Section 23532(2)1 �, All roofs shall be inspected prior to any roofing material being installed.
C]Yet
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
I hamwous air contaminants as defined by the Bay Amo Air Quality Management all new materials for inspection.
tricl7
E]Yet Bdam
I have mad the hazardous materials requirements under Chapter 6.95 of be Califor.
Id-
lmalth&Safety Cade,Sectio¢25505,25533 and 25534.1 undcrstad that if the building
not comedy he .tenant.Nat it u Pa..oh m he I.,the a uyypYYent of be
immeoswho, Chemet scan ,Ima�epan R� Signature of Applicant Date
nerzad agent 7yp//D,te All roof coverings to be Class"B" or better