07090029 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
� TCITZ TIY 'TT(�lY:
-- PERMIT NO.
BUILD NGS+ DRESS:
�Ot5�6 ELENDA DR K & M DEVELOPMENT INC 07090029
PERMIT i95UF DATE
'R'S NAME:
ALICE TAN 1060 W FILL CT 09/17/2007
SANITARY NO. CONTROL NO.
PHONE:
(408) 253-9787
BUILDING PERMIT INFO
ARCHPCEcTIENGINEER: BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
u I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;UE withScction7000)ofDivision3oftheBusinessandProfessionsCode,andmyIkenseis REVISIOI`-DOOR BETWEEN DINING/KITCHEN ON RIGHT
;<y in full force and effect
�z Li".1—Claz Lic.A �/�� SIDE. 2 WINDOWS IN KITCHEN.OPENING TO FAMILY RM
Date ARCHiTECTStDECLA A17�N f� r �
G MOVED TC THE LEFT. ORIG PERMIT #07050082—NO NEW
;5-4
< l understand my plans shall be used as public records
iyU
w h Licensed Professional
OWNER-BUILDER DECLARATION
j< I hereby affirm that 1 am exempt from the Contractor's License Law for the
-p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
e�-9 which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
nt t PP �` g ;;q.Ft.Floor Area
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $0
4 H (commencing with Section 7100)of Division 3 of the Business and Professions Code)or
.. that he is exempt therefrom and the basis for the alleged exemption.Any vitiation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(SM. 3263002-':
�
❑I,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.7044,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 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.).
❑I,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 builds or improves thereon.and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
C]1 am exempt under Sec B&P C for this reason
r Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for WorkeesCompen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Workees Compensation Insurance carrier
raand Ppliry number are:
Carrier.s7 ��' ��`��7'C t Olicy✓Na.:L
CERTIFICATE OF EXFAFIION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is far one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
tYt the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
V Q 1 certify that I have read this application and state that the above information is
CI. ►+ correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
tE"y liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
t-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGU
Re-roofs
ppb H on DOUS TERIALS DISCLOSUR Type of Roof
Will the appli t or future ding occupant store or ha Ic hazardous material
defined by the Cope ' rcipal Code,Chapter 9.12,and the Health and Safety
e,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes °
Will the applicant or future building occupant use equipment or devices which
If a roof i;installed without first obtaining an inspection,.I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? `
❑Yes Jai
1 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
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements which m t • to issuance ofa ertifcate : pananey Signature of Applicant Date
All roof coverings to be Class 'B' or better
O orired ag Date