09020102 Permit CITY OF CUPERTINO
BUILDING DIVISION PERMIT C� TF IL1 ;I� } Ms � 3N.
BUILDING ADDRESS: PERMIT NO.
11238 B BB RD (`TTP_P._RrP__N0 KITC EN DESIGNS nqn2nin2
PERMIT ISSUE DATE
'VNER'S NAME.
2 BE A CONTROL NO.
PHO
408) 257-4900
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
'may in full force and effect. Lica fpgbYb NON—STRCTRL KTCHN RE—MODEL(160SQ) ;NO RE—RF
j Z License Class �-
y Date 9/2 /0 4 Contractor Qa.«c w-/Lilo4 eel,
T ARCHITECrS DECLARATION
C2 U I understand my plans shall be used as public records
a
4 u.H Licensed Professional
rn 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
$Qi 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
F s C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
Y F- (commencing with Section 7000)of Division 3 of the Business and Profauions Code)or 6 O O 0
f 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 APN Number Occupancy Type
not more than rive hundred dollars(M). 36206033 . 00
❑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 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 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 docs 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 Sea B&P C for this reason
wrier 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 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.
❑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 Worker's Compensation Insurance carrier and Policy number am:
Cartier.'4-400a=v5, rt�_PolicyNo.: 4i67—4We'0 Y/0
CE911FICATEOFEX PTION 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z t" 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(Sec.3097,Civ.C.)
W A Lender's Name
az LendeesAddress
U 0 1 certify that I have road this application and state that the above information is
LL" correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorize representatives of this city to enter upon the
above-mcndoncd property for inspection purposes.
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
W) 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 try:
2�(&w
SOU CE REGULATIONS. .
/ � Re-roof s —
Signature of Kpplicant/Conuactor Date T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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
-ale,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Q-No
If a foo 7 is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes L'No
I have read the hazardous materials requirements under Chapter 6.95 of thc 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 must be met 'or to iss w ora fteate or oecapancy. Signaler a of Applicant Date
t'��-1 All roof coverings to be Class''``or better
Owner or authorized ag Datc