07100211 CIT!' OF CUPERTINO = [� T
BUILDtNG DIV1S10N PERMIT �����` `��� ������ `
> ;:, . . :
PERMIT NQ.
BUILD [�ci���.ssgY�E CT CUPERTIl`f0 KITCHEN DESIGNS 07100211 .
FERMIT ISSUE DATE
vER'S NAME: .
VINCENT JOHN V AND LINDA M 10562 S DE ANZA BLVD 10/30/2007
SANiTARY NO. CONTROL NO.
P " o " E : (408)25"'-4900
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECf PLUMB MECH
0 0 0 0
� p 0 LICENSED CON7'RACTOR'S DECLARATION JOb D0SCi11Jt101]
'�� I hcreby afGrm tha� I am licenscd undcr provisions of Chap�cr 9(commencing
';z� wilhSection7000)ofDivision3oflhcBusinessandProCcssionsCodc REFACINCJ FIREPLACE� LIGHTING� INSTALLING GAS
�� a in fuu force an d erFec� � ��' F I RE PLAC; E
� � Z Lice I �. k �
' p Datc Con�ractor
: E" � ARCHITECTS DECLARA ON
i a .a
a 1 undcrstand my plans shall bc uscd as {wblic rcrnnls j� ��
)yU w
' u. F' Licensed Pcufcssional
� � < OWNER-BUILDER DECLARATION
j a� f hcrcby atTirm that I am cxcmpt Gum thc Contractor's Liccnse Law for �he
. p O Collowing reason. (Sccuon 7031.5, Busincss and Profcssions Codc: Any city or coumy
<,° � which tcquires a pertnit to conswct, altcr. im�mvc, dcmalL¢h, or repair any suucwre �
�"� prior to i�s issuancc, alsu rcquires ihc applicant for such permit to filc a signcd sutcmcnt � V3�ll8C10❑
�?< �hat hc is IiccnseJ pursuant to thc provisions of thc Comracwr's Li��cnsc Law (Gapux 9 q. Ft. Floor Area $15 0 0 0
� H� (commcncing with Sccuon 7O00) of Division 3 oC ihc Busincss and Profcssions Codc) or
��., that he is exempt tAcmtrom and ihe bazis Cor ihe allcgcd exempdon. Any violation oC OCCUP1I1Cy Type
Secdon 7031.5 by arry applicant for a permit subjecu �he applicant to a civil penalty of 3 5 716 0 8: L�'8� Number
irot more than Crve hundred dollazs (5500).
0 I, as owncr o( ttie property. or my employees with wages as their solc compensadon,
wi{1 da chc wark. and the suuctuz is not intendcd or afTaed tor salc (Se:'.7044, Business Required Inspections
and Rofessions Code: The Cantcacmr's Licenu Law docs not aPP�Y a��"'"OC of
propeny who builds or improves thueon, and who das such wwk himself or Ihrougfi his
own amployces, providcd ihat such improvements are not intended ar oRered (or sala [C.
however. U�e building or improvement is sold within one year of complction, d�e owner-
builder wiil have ihe burden of proving IAat he did not build ar improvc for purpase of
sak.).
❑ I, as awner of the property, am e�cclusively conuacting wi�h limnsed rnnuadors W
conswct the projea (Sec. 7044. Businas and Professions Code:) The Contractnrs Li-
cenx Caw docs aot apply in an owner of properry w6o builds or impmves tMereon. and ,
who conuac�s far such p�ojects with a contnctor(s) licensed pursuant to �he Convactor's
� �cense Law.
' am ezempt undu Sec. . B& P C for �his rcason
..,vner Date _. .
WORKER'S COMPENSATION DECLARATION
I 6ercby aflirm under penalty of perjury nne of �he following declarations:
❑ I hs.�e and will maintain a Ceni6cate oC Conunt to xlf-insure for Workcfs Compen-
satian, as provided for by Section 3700 of [he Labor Code, for the perfornwnce at the
work for wAich Wis permit is issued.
0 I have and will maintain Worlcer's Compensation Insunnce, u required by Section ,
3700 oC �hc Labor Codc. Cor thc performance of the work for which ihis pecmit is is:ued•
My Worker's Compe tauon Insurance �er and Policy number are:
� , /�� ��p
Cartier. "Pol'u.y No.:
CERTIFICA OF EXEMPTION FROM ORKERS'
1 � �, , `� COMPENSAT'ION INSURANCE
(ihis scctlan necd no[ bc completcd i( the permit is Cor onc hundred dollus (S t00) ,
nr Icss)
I ceni[� ihat in thc perfarmancc of thc work for which ihis permit is issucd. 1 shall not
employ any person in any manner so as to become subject to ihe Workers' Compensation
Laws oCCalifomia Date
Applicant
NOTICE TO APPL.ICAM: If, aftcr making �is CeniCica�c of Excmption, you slwuld
bccome subject to the Workcr's Compcnstition provisions of �hc LaAor Codc, you must
� z farthwith comply wi�h such provisions or this permit shall bc dccmcd ccvolccd.
Z O CONS7RUCTION LENDING AGENCY
[.~.� ��-. I hcreby aCfirm that thcre is a consuuctinn Icnding agcnry (or thc performarkc of �
�C, � ihc work (ur which this pertnit is issucd (Scc. 3097, Civ. C.) ,
W Q Lendcr s Narnc
� z Lcnder's Address
I certi(y ihal 1 have rcad this applica�ion and sta�c �hat thc above infortnatiun is
� O cortcc� I agrce to comply with all city and county ordinances and sta�e Iaws rclaung w
rJ U 6uilding conswction, and hcrcby authori�e rcprescntalivcs of U�is ci�y to cmcr upnn ttic
abovc-mcntioncd propcny for inspcction purposes.
�"' a (Wc) agrce to save, indcm�ify and kecp harmless the Ciry oC Cupertino against
�� liabilitiu, judgmcn�s, eos�s and expensc: which may in any way acccue against said City
V z in consequeace of �he granting of this permiG Date /��� �L����
� AP LI ANT UNDERST DS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SO E ULATION
�L-.
Re-roofs
Sign ure af ApplicanUContractor T e of R oof
HAZARDOUS MATER[ALS DISCLOSURE YP
Wi►I Ihc applicant or futurc building occupant store or handlc harudous mucrial
,cfined by We Cuperti o Municipal Codc. Chaptcr 9.12, and the Hcalth and SaCety
..alc. Scction 25532(a)? � All roofs �hall be inspected prior to any roofing material being installed.
�y� No .
wll Wc applicant or futurc building occupant usc cquipmcnt ar �icviccs wh�ch
If a roof i� installed without first obtaining an inspection, I agree to remove
emil haiatdous air conu nan�c az dcfncd by Ihc Bay Arca Air Quality Managcmcnt all new m aterials for inspec 110[l.
Disuict?
0 ycs � No
1 havc read �he ha�ardous ma�crials requircmcn�s undcr Chaptcr 6.95 of thc Califar-
nia Hcalth & Safcty Codc, Scctions 25505.25533 and 25534.1 undcrstand �hu iCihe buiWinB
docs not curtemly have a ten 4�at it is my msponsibilily to notify the oc�opant o� �he
rcyuirc n w4iGL�_mustbc etprior issuancco(aCcnificaicof O SignatureofApplicant Date
All roof coverings to be Class "B" or better
Owncr thori�cd agcn� ��