07060002 CITY OF CUPERTINO
BUILDING DIVISIONPERMITPERMIT NO.
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BUILDINC�i�1pD "bAR THREE DR TBD — r'0 BE DETERMINED 07060002
OW NElR's NAME: Y PERMIT ISSUE DATE
MATT & VIRGINIA SCHWIEBERT 06/01/2007
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
U
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z W with Section 7000)of Division 3 of the Business and Professions Code,and my license is KITCHEN REMODEL, NON STRUCTURAL W/LIGHTING.
;?y in full force and elIccJ.,
nse Clas Lie•g CONTRACTOR S.F. HOME DECOR PD FOR BUS LIC
it
Lice
1 F w DamARCHECT S�DECLARATI s
IT06/01/07
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W U tt I understand my plans shall be used as public records REC B:i 0 0 0 0 015 2 0 .
.o
mH Licensed Professional
OWNER-BUILDER DECLARATION
> I hereby affirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
x G that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area $12000
2 F $ (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 356070-;7 .
�Number Occupancy Type
not more than five hundred dollars($500).
0 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 docs not apply to an owner of q p
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 saki.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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors 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 Contractofs
License Law.
0 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:
0 1 have and will 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.
❑1 have and will maintain Workers 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 and Policy number are:
Carrier:&6.,oA hpo 14!4. Policy No.:w;a a
CERTIFICATE OF EXEMPRON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone 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'Compensadon
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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z� CONSTRUCTION LENDING AGENCY
E~+ I hereby affirm that there is a construction lending agency for the performance of
0.!•� the work for which this permit is issued(See.3097,Civ.C.)
W Q Lenders Name
az Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
CL t•-i correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
Uahove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
c,] liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►'� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b;
SOURC GU TIONS.
�j� amu; � `f/��' Re-roofs
Signature erApplican tractor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes L�ft`to
0the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Will emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r Iaterials for inspection.
District?
0 Yes W41,
I 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
re wrc whi must be tssuancc of a Certificate of Occupancy- Signature;of Applicant Date
li//�O�'
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-/ All roof coverings to be Class'B"or better
Owner or authorized agent Date