07060140CITY OF CUPERIINU
BUILDING-MVISION PERMIT
BUILDING ADDRESS:
22044 BAXLEY CT
OWNER'S NAME:
ONG RANDY T AND EVA S
'E:
ARCHITECT/ENGINEER:
p Q LICENSED CONTRACTOR'S DECLARATION
iP 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
= y in full force and L y 4i Q, 1
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Lice so
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ARCHITECTS DECLARATION
!W < I understand my plans shall be used as public records
)yU
tL F' Licensed Professional
< OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
:00 following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
" H prior m its issuance, also requires the applicant for such permit to file a signed statement
? < that he is licensed pursuant to the provisions of the Contractor's License taw (Chapter 9
Z H (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their solo compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U-
ccnse Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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J I have and will maintain a Certificate of Consent to self -insure for workers Compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
Nork for which this permit is issued.
] 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. A C O S Policy No... b- O 0�k S4 I, O 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ 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 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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lenders Address
I 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
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR RE ULA :.an
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Signature of ApplirandContraz r Date �
HAZARDOUS MATERIALS DISCLOSURE
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)?
❑ Yes
Will the applicant or future building occupant use equipment or devices which
:mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes Wu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have tenant, that' is my responsibility to notify the occupant of the
requirements whit t be met w is.^ c of a C:rZtjr1 ale f Oc, cuganc]�2
Owner or authorized
PERMIT NO.
R.K. BERRETT CONSTRUCTION 107060140
11117 + I PERMIT ISSUE DATE
6151 CALLE DEL
SANITARY NO. CONTROL NO.
(408) 263-0530
BLDG
BUILDING PERMIT INFO
Job Description
KITCHEN REMODEL, STRUCTURAL EXTERIOR AND
INTERIOR,
NEW WAL:� IN LIVING ROOM
3q. Ft. Floor Area
3560603 ) .,V�TNum
0
Issued by: .01
Re -roofs
Type of F.00f
$110000
Required Inspections
vaivatlon
occupancy type
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof i s installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
ignature of Applicant
Date
JAll roof coverings to be Class "B" or better