03070046 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT • CONTRACTORaINFORIMATI
BUILDING ADDRESS: PERMIT NO03070046 3070046
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL N0.
ARCIi1TECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH l
100 LICENSED CONTRACTOR'SDECLARATION Job Description
4 Vm affirm that I am licensed under provisions of Chapter 9(commencing
nU with Section 70(0)of Division Softhc Busincssand Professions Code.and mylicensc is
1.ferce License Class d effect. Lie.# ADD 171 SQ. FT . /KITCHEN REMODEL
e Date Contract.,
ARCHITECTS DECLARATION
1 understand my plane shall he used as public records /J(L/
! � L
=o In Licensed Professional W,
3 OWNER-BUILDER mDECLARATION
COO I naso affirm that I ore exempt from the Contractor's C License Law for the /
O O which re reason.(Section]1131.5,Business and ve demolish,
Code:Any city or counre
5$ which requires issuance.pmmit enthe alter,nt rrow,do ermit t rte a poi, ed ummerc
hit he i¢ ensedore requires,tohe the applicant for such ConrcrmrUnrlcse,Law naemem
< that heislimnuJpuruanUolhepmvisinnsnfthe Contma't.rsLianxl�w(Chaper9 Sq.Ft.Floor Area Valuation
eH (commencing with Section 7W0)ol Division 3.fthc Bminesa.md Pmfessi.n.Code)ser Y
e $ that he is exempt therefrom and Ina basis for the alleged exemption.Any violation of 32649024 . 00
Section?831.5 by any applicantfor a permit subjects Ne applicant to a civil penally of APN Number Occupancy Type
not or.then five hundred della.(5500).
❑I,s owner of the property,.1 my employees with wages ss their sole compensation,
will do the work,and the suichim is not intended or offered for sale(Sec.7044,Business 101 — eTggKd Inspections
and Proassi.m Code:The Contractor's License Law does not apply Or an owner of 10 2 - PIERS
property who builds or improves thereon,and who does such work himself orthrougb his
rvn employees,provided that such improvements are not mended or offered for sale.If. 103 — UFER
however,the haildi all or impmvem=nt is mid within one year of completion.Ne owner.
builder dl have the burden of proving Nat maid not build or imponafor purpose of 104 _ REBAR
•ale' 105 ANCHOR BOLTS
I,as owner of the reopen,am exclusively contracting with licensed contractors to 106 — SEWER & WATER
consumer the project(Sec.7044,Business and Professions Code:)The Contractors Li
cense Law doesnot apply to an owner of progeny who Wilds or improves thereon,and 202 — UNDERFLOOR PLUMBING
who Comracufor such projects with a com.ctor(s)licensed pursue ml to the Contractors
Lkense Law, 203 — UNDERFLOOR MECHANICAL
0 Onexempt.nx _.a&PC for this...n 204 — UNDERFLOOR FRAME
owne, Date 205 — UNDERFLOOR INSULATION
WO (ER's M ENSATI NDECLARATION
I hereby 7)it of perjury one of the following declarations: 301 — ROUGH PLUMBING
l mwandwiii an0 in aCemre.te of Consent m sel&iaeere for workers Com,en. 302 - TUB & OR SHOWER
cation,.povided to,by Section 370 of the Labor Code,for the poff......f the 3 03 — ROUGH MECHANICAL
work for which this permit is issued.
I have and will maintain Worker's Compensation Tnsu.nce,as Ieyvited by Sermon 3 04 — ROUGH ELECTRICAL
3700 of Ne Labor Code.for Ne performance of the work for which Nis permit is issued. 305 — FRAME
My Worker's Compensation Insurance carrier and Policy number are: 306 — HOLDOWN6
Cartier. Policy No.: _
CERTIFICATE OF E%EM MON MOM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
(This section need not he compmedHite permit is Tor one hundred doll,.tila0 309 - EXTERIOR LATH
or lcsx)
I certify that in the performance of the work for which this permit Is Issued.I shall nut 310 — INTERIOR LATH
employ any Person in any manner so as it)become subject to the Workesi Compensation 311 o SCRATCH COAT
Laws of California.Da
Applicant le 313 — ROOF NAIL
Laws
NOTICE TO APPLICANT:If.after making this Confiscate of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subjeet to the Wo,kce's C.mr nsta on provisions of Ne Labor Code,you must
.JZ forthwith comply with such provisions or this permit shall be deemed revekcd. 502 — FINAL PLUMBING ENERGY
zoCONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
t,..t tNr (hcrchy affirm that Nero is a construction lending agency fur the Performance.( 504 — FINAL BUILDING ENERGY
LYi the work fur which this mit peris issued(Sec.3(197,Civ,C.)
W q Lanai Name 505 — FINAL ELECTRICAL
z LendersAddtess 506 — GAS TEST
U O 1 certify Nat l have mad this application and sue that she.how information is 507 — FINAL PLUMBING
correct.I agree to comply with all city and county ordinances and state laws relating to
p U buildingconawcuon,andherebyauthorim«prosentadwsofhiscitytoeneruponthe FIN MECjtNG AL
W ah.vomentioned progeny for inspection purposes.
y (We)agree to saw,indemnify and keep harmless the City of Cupertino against 0 9 FIN
.y rq Iiahilitics,judgmenLxcosts and cx,emaswhich may inany way accmcagainst said City 5 U Z In consequence of the grab ng of this permil.APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by:5 ORKS Date
SOURCERE ATIO S/
Re-roofs ''TT77
S nature of App i ant/ ontr ctor Data fV\ /.._ ._
HAZARDOUS MATERIALS DISCLOSURE Type of Roof �, C
Will the' pliant or future building Occupant store or handle hxemdous material (((
as defined by the Cupertino Municipal Calc,Chapter 9.12.and the Health and Safety
Calc,Section 25532(.)7All roofs shall be inspected prior to any roofing material being installed.
O Yes
Will the applicant. mtur building Occupant ase equipment Or devices which .If a roof is installed without first obtaining an inspection,I agree to remove
mit baMous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
DLtrlC17
❑Yes N'
maNn ma
I have read the hteriab reyuiremcntsunder Chapter 6.95 ofthc Califon
nixHealth&Safny Code,Semens 255115,25533 and 25534.1 unescomnd the iftM Wilding
does not en mently how a motion,that it is my feerkosibility to notify the occupant of the
myviremcnu fonm..t Uma nytaniMuanee.r.CeniEeae.faeupancy. Signature of Applicant Date
cr or aaho red agcm t Date All roof coverings to be Class "B" or better