06120096 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
� 1NTA CTQR IdZTI�N:
PERMIT NO.
BUILDING ADDRESS:
888 BLAZINGWOOD AV BARCZI Y:ENN
PERMrr ISSUE DATE
OWNER'S NAME: DO 1 O 4 Z O O 7
BARCZI KENNETH A AND JOANNE B
SANITARY NO. CONTROL NO.
LONE:
BUILDING PERMIT INFO
ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH
!00 LICENSED CONTRACTOR'S DECLARATION Job Description
4 U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z with Section 7000)of Division 3 of the Business and Professions Code,and my license is KITCHEN REMODEL NON—STRUCTURAL
y in full force and effect.
License Class Lic.S
t-0
—0 Date Contractor
ARCHITECTS DECLARATION
ce U 1 understand my plans shall be used as public records
a
L O H Licensed Professional
-0, OWNER -BUILDER DECLARATION
M 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
E a O following reason.(Section 703 1.5,Business and Professions Code:Any city or County
K m� which requires a permit to construct,alter,improve,demolish,or repair any structure
Z Y prior to its issuance,also requires the applicant Car such permit to file a signed statement ; .Ft.Floor Area Valuation
fE that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 (I $25000
z (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6 917 01<3 Number
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7041,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for We.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
M-16 owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7041,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for thisanon
Owner � �Date l l t1To
ORKER'S CO GNSX11ON DECLARATION
1 her y affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance or the work for which this permit is issued.
My Workces Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner to become subjcct to the Workers'Compensation
Laws of Californill.Date
Applicantp C �`'� '
NOTICE TO AP CANT:If,after maki!i< ertdi ate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J'-J.,, forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(�r� 1 hereby affirm that there is a concoction lending agency for the performance of
fx> the work for which this permit is issued(See.3097,Civ.C.)
W A Lender's Name
a+ L.cndces Address
U O 1 certify that 1 have read this application and state that the above information is
" correct.I agree to comply with all city and county ordinances and state laws relating to
LL
LJ- U building construction,and hereby authorize representatives or this city to enter upon the
above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
tE.
.0 liabilities,judgments,costs and expenses which may in ahy way accrue against said City
WITH ALL NON-POINT
V Z in consequence of the granting of this permit. Date
0-0 APPLICANT UNDERSTANDS AND WILL COMPLY Issued by:
SOURCE R GULATIONS.X1"aft L//G �j
'&-s d / Re-roofs
Signature pplicanitContraetor Dam T of Roof
MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C1 Yes ED N6
If a roof.s installed without first obtaining an inspection,I agree to remove
Will the applicant or rotate building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
❑Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be mel . 10,ssuan of a certificate er occupancy. Signature of Applicant Date
Date All roof coverings to be Class"B"or better
Owner erthorizcd agent