07010151 CITY OF CUpERTIlNO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: ,
20371 — PERMIT UE DATE
OWNER'S NAME: 01/24/2007
MAJEWSKI MARC AND KOLSTEE- SANITARY No. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
J a o LICENSED CONTRACTOR'S DECLARATION Job Description
v 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
e-Z� with Section70(M))ofDivision3oftheBusinmandprofessionsCode,andmylicenseis KITCHEN REMODEL—NON STRUCTURAL, EXTEND (E) GA
=y in full force and effect. LINE.
? License Class Lia N
2 Date Contractor
u ARCHITECTS DECLARATIO
E- N
g w U I understand my plans shall be used as public records
a
t m y Licensed Professional
a a OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Cod c:Any city or county
K which requires a permit to construct.alter,improve.demolish.or repair any structure
a' prior ui its issuance.also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
-?< that he is Iiccnscd pursuant to the provisions of the Contractur's License law(Chapter 9 (1 $24839
x F$ (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 Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3693601
Vi.11
ore than five hundred dollars(5500).
as owrtcr oC the property,a my employees with wages as their sole compensation, Required Inspections
o the work and the structure isnot intended or offered for sale(San.7044,Business
and Professions Code:The Contractor's License Law docs 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 sale.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.).
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who d
who contracts or such projects with a contractor(s)licensed pursuantt to the Conractor's
License Law. g&P C for this reason
1 am exempt under Sec.
Owner L� �r /i'1 5.& Date z 'r'O}
WORKERS OPNIMMAI iON DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and wi11 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 of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is or 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 so as to become subject to the Workers'Compensation
Laws of CalifpSrtia.Ditto a! -40
Ty F
Applicant
NOTICE TO APPLICANT:If,a r making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
[�rA 1 hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
(San Q
Lender's Name
a Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
17. [_ cored.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of 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
liabilities,judgments,costs and expenses which may in any way accrue against said City / (� —7
U Zin consequence of the grating of this permit. Date — 2. /�� /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued l:y:
SOURCE REGULATIONS.
Re-roof
Signature ofApplicant/Corit&ctor Dare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hayardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? ��/' All roof.s shall be inspected prior to any roofing material being installed.
❑Yes CJ No
If a roo-is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
L
t�read the hazardous materials requirements under Chapter 6.95 ofthe Califor-
afctyCode,Sections 25505,25533 and 25534.1 understand that ifthe building
ntly have a tenant,that it is my responsibility to notify the occupant of Ne Date
which must be met prior to issuance of a Certificate of Occupancy. signature Of Applicant
-: All roof coverings to be Class"B" or better
thorized agent
Date