08100030 CITY OF CUPERTINO h 'vx,��•,�wa etre+'X r-y`.. wi,i7�^As� e �' rx�`- fi
BUILDING DIVISION PERMITG�f)1RAC'.COR Il�' URMATIONk
BUIINGr DRESS: PERMIT NO.
LTM YORKSHIRE DR CENTRAL COAST CONSTRUCTION 08100030
41PER'
4844 CLYDELLE AVE 10/06/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 858-6417
ARCHTIRC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a0p LICENSED CONfRACIDR'S DECLARATION I Job Description
1 bunchy Aprea thas 1,m licensed under pmvivmu of 0smser 9(Comane
ming p
_ withseetion 70110 orDividon3ofthc eusiwoane Proteuwns ander Ikenmu KITCHN RMDL MINOR STRUCTRL(479SQ) & SVC UPGRD
in full force and elle,. 9-
j�_ Lkense Cl Lk.g O
Date Chatham,
MARCHTTECPS DECLARATION
? U 1 understand my pluu shall W used u public records
to
Licensed Professional
3 OWNER-BUILDER DECLARATION
a� E 1 hcrtby aRm Nal I am Comma from Om Contractor's License law for the
0 o following moon.(Sudan]U31 S,Business and Pmfcssioo Code:Any city m county
K 3 f which requires a permit to consmuct,altar.improve,demotmh,m repair any structure
u i y prior m its issuance.also requires the appliom forwch permit m Ek aligned sutamml
EiC wa he is licensed punoam to we provisions of the Comames liana Law(Chmus,9 Sq.Ft.Floor Area $g2000 Valuation
f do
,1- (commencing with Seeds.7000)of Division]oBusiness and Pmfcasions Code)or
to that W Is aompl therefrom and 0m basis tar the alleged esempdon.Any violation at
Schon 7071.5 by airy applicant for a permit subjects the applicant m a Civil penally of Number Occupancy Type
anthen five hundred dollars( 5 k 36207025 .'
0 1,as owtrs of the property.or my employees with wagns as them sale Compensation,
will do the work,and WC smcture oman inrendcd ler alfcred Waste(Sec.]ON,Business Required Inspections
and Professions Code:The Conmeomrs Licence Law docs wee apply m ns an owner of q p
propenywho ddWamirmu ves thereon.and whodoesauch warkhimxltor through his
own employees,Provided that such improvements art at intended mofr.d for sale V.
however.We Wilding or irepmvemrnt is sold within Case year of ocmpmtior.the owor-
Wilds,will have the Wrdm of proving Wal he did vel Wild or improve for purpose of
Cam-).
0 1.as ower of We pmpeny,am solusively contracting with licensed awactms to
coormtt the project(See.70sd.Business and Professions Cade:)Tho CantrnmYs U.
C.law dao vel apply m an owner of property who Wilds an improves Wemun,,nd,
who concocts for such projects with a comancmr(s)licensed pursuant to six Comsu m's
Lictnse law.
0 lamoem"womn Sec ,Bk PCfarthureom
nee Date
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under penalty of perjury are,at the fellomot dealam an..
❑I have and will maintain•Cenificea at Consent w alt insure Iso Wmkcr's Compen-
wimt,as provided for by Section JTW of the labor Code,fm We performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Comperu,don Insurance,as regdred by Section
JRD of the later Cade,
fm the performance,of he wok fm wbich this permit u
iouni.
MyWorke� ,dTcxdunandPolirynurnberam:
FROM WORKERS'
COMPENSATION INSURANCE
Oldsmeaden need not W completed lithe permit is fm ave hundred dollars($100)
car mu.)
I wlify that in We performance of We wart fm which Wu pewit is issued.l shall no,
employ any person in any mamerse,a to became sabjecl to the Work a'Comperaation
Laws of California.Data -
Applicm,
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should
become subject to the Warke's Cnmpeo ration provisions of the labra Cade,you such .
.,O farNwith comply with such Provisions or this permit"I W deemed revoked.
'Z'
ti tV) CONSTRUCTION LENDING AGENCY
[-t Thor whicBrmthe there uacousmcti097.Cr,.g agony,for the perfwmance of
(L We wash for which Nis permit m issued(Sec.709'1,CC.)
Qlandm's Name
z Lenders Address
U O 1 curtly that I have read tiro implication sed rale Wu thus above information u '
gy^ corrnL 1 agree to comply with all city and county ordinances and sale laws relating to
CSJ' Wilding coomuctian,and hereby authorise representatives of this city m ental upon We
W Anwe-mentioned property for inspection puryoes
gL (We)agree to on.indemnify and keep barmless the City of Caperton agmen
N Iiabilites.jndgmmts,cotsandexpeaso whichmay in mywayaccom sgaimsoid City
U z inc of granung of ' permit. /
b -41'-OP Re-roofs
Si ppli uConu ccur Data
/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
I do appliance ler forum building occupant store m handle haordoo material
defined by Ne Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
.Section 15571(.)] �� All roofs shall be-inspected prior to any roofing material being installed.
DYo 0No
Will the applicant ler future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
until hazardous air emmo inma as fined by dm Bay Arra Air Quality Management all new materials for inspection.
DWHct7
D Yes No
1 hwc mad Ne hmardvwmatarislsrequiremcnu under Chepms 6.95 of Ne Caiifw-
niaFlmith&Safety Catle.Scetiw 25 ,155]7 uW2553a.1 unMraand thaifthe Wingng
docs net Corse.Y wa tananl u my ropeastj ily m wtify the o cupam Of We
Dam'
P