07020118 U. �Q IQRMT� * PERMIT NO.
CITY OF CUPERTINO PERMIT 07020118
BUILDING DIVISION
PRUDHON Bt J I LDER S nRMrr ISSUE DATE
BUIL ING A9DRESS: --� 0 2 2 3 2 0�'�
09 b 7 FAIRWOODS C CONTaoL No.
OWNER'S NAME:
1096 NORF DLK DR SANITARY NO.
V INCE GRELL I (408) 390-7251 BUILDING PERMIT INFO MECH
SNE: BLDG ELECT PL
UMB
ARCHi1ECTIENGINEER: Job Description
LICENSED CONTRA RS DECLARATION
ionsofChap KITCHEN itEMODEL AND WINDOW
REPLACEMENT.
i O o under provisions of Chapter 9(tom cense s
m i= 1 there y affirm
that I am licensed L
I v V with Section 7000)of Division 3 of Ute Business and l'fissions7 •and my NON S TRU'.~-TU1ZA
i"Nll forte and feet. Lic.1f
z License Class a;^O y _Contractor
ARCHITECTS DECLgRATI N
y� Date plans shall he used as Public records
7 ode e I understand my p
'a'
W y Licensed Professional OWNER-BUILDER DECLARATION
o t from the Contractor s Liccn ci�or cooumy Valuation
"� I hereby at' that I am exempt
air any structure $60000
rove,demolish,or cep jq Ft.Floor Area
p O following reason. ermiOto7constr le ptplicamp rand such ermiCto rile a signed statement
60 which requites a pe uitcs the applicant for such Ik Occupancy Type
prior to its issuance,also req iovisions of the Contratiur's License Law(Chap 9
-z< that he is licensed pursuant to the of Division 3 of the Business a"uon.Any violation of Nprofessions CD�c)or umber
ti E e (commencing with ScctfLam )and the basis for the alleged exel cant to, civil penalty of 3 5 91311
It that he is exempt therefrom
for a permit subjects the app
Section 7031.5 by any aPP 044,nsation, Required Inspections
not more than five hundred dollars(5500) ccs with a as their sole compe
(]I,as owner of the property,m my employ
Contractors License Law dors not apply to an owner of
will do the work and the structure is not intended or offered far sale(Set.C g"
h hia
and processions Code:The nand who does such work himself
property who builds or improves there° not intended or offered forsale-
ner-
that such impis sold it are Year of completion,the
own employees.Provided., or mproveme"t is sold within one y improve for purpose of
however,the building roving that he did not build or imps
builder will have the burden of p
tors to
sale.). in with licensed con c Li-
am exclusively contract g TheComae
01'as owner of the property who builds or improves thereon,and
construct the project(Sec.704t,BList and Prof who bu Coda
cense Law does not apply to an owner of property d pursuant to the Contractor s
who contracts for such projects with a contractor(s)license P
B&P C for this reason
License Law. t under Sec.
1 am exempt Date -_�
owner �yORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury"rte of the following declarations:
3100oC the Labor
((��I have and will maintain a Certificatee Code.for he performance of the
of Consent to self-insure for Worker's ompe-
7Lion,as provided for by Section
/!w"oo'rk Cor which this permit is issued• uircd by Section
nsaton Insurance,as req Emit is issued.
(]t have and will maintain Wo performaces nce of the work for which this pe
3700
of the Labor Code.for
the
lmsurance carrier and policy number arc:
My Workers Compensationpolicy No
Carrier. CERTIFICATE OF EXEMFfION FROM WORKERS
COMPENSATION INSURANCE
This section need not be complcud if the permit is for one hundred dollars($100)
°r less.) permit is issued.I sh
performancenot
of the work for robj ct to the Workers Compensation
I 1plo;fv Utah in the inany manor so as to
employ any pets" -1
Laws of Cahfo •a.Date tion,you should
Applicant I,atter making this erificate of Exemption, You must
NOTICE To APPLICANT: tion provisions of the Labor Code.
become subjcM l0 thew Compc unit shall be deemed revoked.
Z forthwith comply with such provisions or this Pe
0 CONSTRUCTION LENDING AGENCY tor performance of
, I hereby affirm that them is a construction lending agency
-+ unit is issued(Sec.3097.Civ.C-)
H
> the work for which this pe
Lender's Name
2 Lender's Address
I certify
that 1 have read this application and start that Ute above information is
es
te
V C) cortcct I agree to comply with all city and cou`escntatily vestof this city o cntcr upon the
u"(•' building construction'and hereby authorisrCP
U about-mentioned Property for inspection purposes-keepl ess the city of Cupertino against Date
�+a (We)agree to save,In It
ses which may in any way accrue against said City
H liabilities,judgmcnu.cosu and expo
VZ in consequence aC the gran f AiN rW I
*-� APPLICA UNDER WILL COMPLY WITH ALL NON-POINT Isis ped y
SOURCE GU DER —Z3^02 Re-roofs
Date Type of Roof
°I re 0 PPI' it
prior to an g aterial being
installed.
11pypRDOUSMATEa��tssorcOOshandlcha7ardousmatcRE rial y roofing m
will the applicant or future building an inspection,l agree to remove
c°pe All roofs shall be in p
as defined by rhino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(x)? No If a roof is installed with
first obtaining P
oyes materials for inspection.
occupant use equipment or devices which
the Ba Arca Air Quality Management a 1 new
Will the applicant or future building P
emit hasardous air contaminanu as defined by Y
District? I)(I No
O Yes yi ter 6.95 of the Calitor-
Date
Com,Srd0us s mater"'25533 and 25534.1 understand that if the building -
1 have read the hazardous materials requirements under Chapter the occupant of the Applicant �� or better
niaHealth&Safetyharo a fit,that it is my responsibility t°notify t;ignature of App e Class,B
does not currently et r w issuance of a Certificate o�Oc ��� All roof coverings to b
rcquircmen which must P
Date
.. .. thnri7.e a cnt