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CITY OF CUPERTINO
BUILDING DIVISION PERMITPERMIT NO.
BUILD11VI""RORMANDY CT TBD TO BE DETERMINED 07060076
OWNER'S NAME: PERMIT ISSUE DATE
LAW KINCHO H ET AL 06/11/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 p LICENSED CONTRACTOR'S DECLARATION Job Description
LU r: I hereby affirm that I am licensed under provisions of Chapter 9(commencing
a a with Section 7000)oCDivision 3 of the Business and Professions Code,and my license is KITCHEN REMODEL
in full force and effect
License I s Lic.#
F•, Dam ,� Contrador_
ARCHITECT'S DECLA A
I
< I understand my plans shall be used as public records
aV
1,h Licensed Professional
y OWNER-BUILDER DECLARATION
Z I hereby affirm that I am exempt from the Contractors License Law for the
O 0 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
prior to its issuance,also requires the applicant for such permit to file a signed statement
�<
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft,Floor Area Valuation
tom• (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 3 8
000
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 ofNumber Occupancy Type
not more than five hundred dollars($500). 36929019
❑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 forsalc(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dors not apply to an owner of Q P
property who builds orimproves thereon,and who doessuch work himselCor through his
own employees,provided that such improvements are not intended or offered for sale.Ir,
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.).
❑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[!-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a comractor(s)licensed pursuant to the Contractors
License Law.
❑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:
❑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.
PI have and will maintain Worker's Compensation Insurance,as required by Section
700 of the tabor Code,for the performance of the work for which this permit is issued.
My Worker's' 11'7vC�/l
C^ompensa�tion.Insurance carrier and Policy number are:
Carrier. C3� . L_ Policy No.:714�7) 61
CERTIFICATE OF EXEMPTION FROM WORKERS' - _
COMPENSATION INSURANCE W
(This section need not he 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'Compcasation
Laws of Califomia.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
.J O forthwith comply with such provisions ar this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
C/1
I hereby affirm that there is x conttructinn lending agency for the performance of
Ri > the work for which this permit is issued(See.3097,Civ.C.)
WLR, A Lender's Name
Z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
ry H correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
a ahovc-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
HCn liabititles,judgments,costs and expenses which may in any way accrue against said City
U,Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S URC ULA
Re-roofs
ignaturc Jr Applican anuactor ate
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)?
❑Yeso All roofs shall be inspected prior to any roofing material being installed.
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? .*
❑Yes �Nu
I have mad the hazardouu`s mm-aterials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if the building
does not currently ha a t ant,that it is my responsibility to notify the occupant of the
require s hick u et priorta issuance o(a Certificate of Occupancy ,Signature of Applicant Date
All roof coverings to be Class"B" or better
Owner ora ihorize gent bite'
.r
{ CITY of CUPERTINO
err of
PERMIT APPLICATION FORM
CUPS TING
D7o&0076
APN# 36q— 0 '
Building Address: Mailing Address (if different from building address):
729 Nafmoodo
Owner's Name: Phone #:
1/(IV5v Z^a,� — MorLo Cf euk .25-3- 7/?T
Contractor: 0 W CtJhQYC KP License#:q2-0 103
461
Contact: � // Phone: 3 77-700/ 90t Cupertin Busines cense#:QVY)CKC Fax: 3 77—700 Z
054 A AIAA UA
Building Permit Info:
Bldg �k Elect ER Plumb P�r- Mech L9
Job Description: fr !�n f
Residential � l� !"®u e focdP( Commercial ❑
Sq.Ft. Floor Area: 12-0 Sq.Ft.:
Cost of Project: Oho Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC 1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
X BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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