07100124 CITY OF CUPERTINO " n � `
BUILDING DIVIS10iV pERMIT �������� �����Y'��T��N:,. ::
, _. ,:,, ..
PERMIT NO.
BUILD �x��n��ESS�,I,OKES AV GOFF DE�TELOPMENT & DESIGN 07100124 .
r 'cR'S NAME: I'ET�MIT ISSUE D'`TE
POULSEN BEATRICE M 791 E BF:OKAW RD � 10/17/2007
PHONE: SANITARY NO. CON'CROL NO.
(408) 44__-8076
ARCHI'fECi1ENGINEER: BUILDING PERMI'i'INFO
BLDG ELEC'f PLUMB MECH
� � � �
i p p LICENSED CONTRACTOR'S DECLARAT[ON
� V� ! hcrcby �rm thal I am liccnscd undcr provisions oCChaptcr 9(cammcncing Job Description
; z� wiU� Sccdon 7000) ot Division 3 of thc Busincss and Profcssions Codc, and my licensc is K I TCHEN REMODL & ADD A� C� NO STRUCTRL
: 7 y in full Corce and cff
� v� z Licenx CI Lic. #
+ F �p Datc Conuutor
�,� ARCHl7ECT5 DECLARATION
7 o�C e 1 undcrstand my plans shall be uscd as public rccords
�yU
' u. y Licensed Pmfcssional
� y � OWNER-BUILDER DECLARATION
1 hcrcby atYrm that 1 am cxcmpt Gum �hc Convactors Liccnsc Law for ttrc
� p o Collowing muon. (Secuon 7031.5, Business and Professians Caie: Any ei�y or county
�$�i which rcquires a pcanit w conswct, altcr, improve, dcmolish, or rep�ir any swcture
`? z y pnor u� ils issuance, also rcquires �he applican� Cor such permil to file a signed sta�ement �
�_< that hc is IiccnscJ pucsuant �o thc provisions of thc ConuacWr's Liccnx Law (Chaptcr 9 S q. Ft. Floor Area � 4 O O O O Valuation
u F- �(commencing wi�h Scctian 7000) of Division 3 of Ihc Busincss and Profcssions Codc) or
y �.. that he is exempt Ne�efrom and �he basu (o� U�e allegcd eump�ion. Any viotuion of
Section 7031.5 by airy applicant for a permit subjccu the applicant to a civil penalty of � �p Number Oeeupaney Type
not more than fivc hundmd dollars (5500). 3 2 6 4 8 � Q.. :'CJ �
❑[, u owncr of ttie property, or my cmployca with wages az their sote compensaUon,
will do thc work, and �he stiuctuce is not intendcd or offued tor sale (Sec. 7044, Business Re uired Ins ections
and Professions Code: The Conuactor's License Law daes �rot apply ta an ow�rcr of Q p
propeny who 6uilds w imp�oves thercon, and who dces such work himself or through his
owa employccs, providcd that such improvements are not intended or oRered (or sale. IC,
however, the building or improvement is wld within one year of complcuon. We owner-
builder witl have the burden oC proving Ihat he did not build or improvc fw pmpau o(
sa1eJ.
❑ I, as owner o[ the property, am exclusively conuacting wi�h licensed conuactors to
conswct the projen (Sec. 7044. Business and Protessions Cade:) The Contractor's Li•
ccnse Law docs not apply to an owner of property who builds or improves theteon, and .
who contracts Cor such pmjecls with a conuactor(s) licensed pursuant to tde Convacto�s
License Law.
❑ 1 nm ezempi undu Sec , B 8c P C far Wis rcason
•.r Date
WORKER'S COMPENSATTON DECLARATION "� � .
I IKrcby aflirm under penalry of perjury onc of �he following declantions:
❑ I hs�e and wil! maintain a Certifca�e of Conscnl lo ul(-insure for Workcrs Compen-
satian, as providcd for by Section 3700 ot [he La6or Code, for the pedarmancc at the
work for whicd Ihis pertnit is issued.
❑ I havc and will maintain Workcr's Compcnsadon Insurana, u mquired by Scction
3700 0( �he Labor Code. Cor the performance of the work for which �his permit is issued. '
My Worker's C pen ation In ,{�rance n'cr and Policy numbcr uc:
Carrier. n Policy No.: �� � � `�'� �� ^
CERTIFt ATE OF EXEM ON FROM WaRKERS'
COMPENSA'I'lON INSURANCE
(This sccUon need not bc complc�ed if the pcemit is kx onc hunMed dollazs (5100)
or Icss.) •
i cenify that in thc perCormancc of thc work for which �his permit is issucd. 1 shall not �
employ any person in any manncr so as to bccomc subjcct to the Workcrs' Compensauon
Laws of California. Datc
Applicant
NOTiCE TO APPLICAM: [f, af�r making this Ccnilica�c of Exemption, you should
bccome subjcct to thc Workcr's Compcnsation provisions of �c LaMr Cadc, you must
� O foMwith comply with such provisions or this pccmit shalt 6c dccmcd n.woked.
� "' CONS7RUC1'ION LENDING AGENCY
[-~-� �-�+ I heceby aftirtn ihat thcre is a consuuctinn Icnding agcncy far thc performar�ce uf
p�., � thc work for which ihis permit is issued (Scc. 3097, Civ. C.) �
W� Q Lendefs Namc •
a z L.cnder's Addrcss
(� � 1 certify tha� 1 havc read ihis application and staic �hat U�c abovc infom�auon is
�►�-� cortcct. I agree to comply with alI city and county orJinances and state laws rclating �a
� U 6uildiag conswction, and hc�cby authori�e reprcscntativcs of this city to cntcr upon thc
� a abovc-mcnlioncd property (or inspccuoa purposes.
(Wc) agree to save, indemni(y and kcep hazmless thc City o( Cupertino against i
�� IiabitiUes, judgmcnts, costs and eapenses which may in any way accruc againsl said City
V z �� consequcnce oC thc granung af this permit.
►-� APPLICANT UIVDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGULA7TONS.
Re-roofs
Signaturc of Applicand ntncto atc
RDO ALS DISCLOSURE Type of Ro �f
Will U�c applicant or futurc building occupant store or handk harardous matcrial
ax dcGncd by the Cupenino Municipal Codc. Chap�cr 9.12, and the Hcal�h and Safety
c. Section 25532(a)? All roofs st�all be inspected prior to any roofing material being installed.
❑ Y� ��
Will �hc applicant or futurc building occupant usc cquipmcnt or dcvices which If a roof is ,nstalled without first obtaining an inspection, I agree to remove
cmi� harardaus air conuminants az dcfincd by Ihe Bay Arca Air Quality Managcmcot all new mai erials for inspection.
Districc?
❑ Ycs �o
1 havc ccaA the ha�ardcws matcrials requircmcn�c undcrChap�cr6.95 of �!x Califor-
nia Hcalth & Safcty Codc, Scctions 25505, 25533 and 25534. I undcrs�v�d that if thc building
docs nol curtcntly havc a �cnan4 Wat it is my responsibility w noufy �hc occapant of ihc
myuircm which must bc met rior ' ancc o(a Ccrtificatc of Oc pancy Signature o F Applicant Date
Owner or authori cd agcni ,� All roof coverings to be Class ° B�� or better