06100185 CITY OF CUPERTINO `
BUILDING DIVISION
PERMIT
BUILDING ADDRESS: SEARS HOME IMPROVEMENT PERMIT No.0 610 018 5
939 BUBB RD
OWNER'S NAME:
PERMIT L95UE DATE
HEATHER SIMMONS 283 E. AIRWAY BLVD. 10/26/2006
JNE: SANITARY NO. CONTROL NO.
(925) 245-2000
BUILDING PERMIT INFO
ARCHTfECT/ENGINEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
l hereby affirm that I am licensed under provisions of Chapter 9(commencing
j Z T, with Section 7000)of Division 3 of the Business and Professions Code,and my license is
>>y in full force andcffec KITCHEN REMODEL NONSTRUCTURAL- UPGRADE MAIN PA
j�? License Class Lic.8 200 AMP
t p Date Conlracwr
AR HiTECTS DECLA ATl
'2J
C%.< 1 understand my plans shall be used as public records
.4
o�- Licensed Pmfcssional
h OWNER-BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
`e m ff 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 rile a signed statement Valu i2nl 4 5 8
=G that he is licensed pursuant to the provisions of the Contracwr's License Law(Chapter 9 Sq.Ft. Floor Area
t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of p Number Occupancy Type
not more than five hundred dollars(5500). 3 t7 1 1006 . 00
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 does not apply to an owner of 9 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 sale.lf.
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 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 Contractofs
License Law.
❑I am exempt under Sec. B&P C for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby alum under penalty of perjury one of the following declarations:
Q I 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.
0 I 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 Worke's Compensation Insurance carr and Pojicy nymbcr are:
Carrier. Policy Q
CERTIFICATE OF EXEMPTION FROM WORK RS'
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z . CONSTRUCTION LENDING AGENCY
(~.0 CA I hereby affirm that there is a construction lending agency for the performance of
pC> the work for which this permit is issued(Sec.3097,Civ-C.)
L4 A
Lender's Name
Lender's Address
U 0 1 certify that I have read this application and state that the above information is
r r 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
U above-mentioned property for inspection purposes.
Qr (We)agree to save,indemnify and keep harmless the City of Cupertino against
fn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. /��_
r" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R ONS.
Re-roofs
Signature o pplicant/Contractor r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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)? All roofs shall 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 is installed without first obtaining an inspection,I agree to remove
,:mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes [�Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCode,Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have a tenant,th it is my responsibility to notify the occupant of the
rt:gaire which must be me rior iss cc cc ate oroccu cy. Signature of Applicant Date
Ownor authorised agent Date All roof coverings to be Class"B"or better