06040030 CITY OF CUPERTINO
BUILDING DIVISION PERNIIT CUNTRACTORTINFJR'MIxd (S a.0
BUILDING ADDRESS: A WEI—MIN MA PERMIT. .06040030
1071 PERMIT ISSUE DATE
OWNER'S NAME:
E: SANITARY NO. CONTROL NO.
ARCHn4CT(ENGIKEER: BUILDING PERMIT INFO
BLDGO ELECTO PLUMB MECHO
�op LICENSED CONTRACTOR'S DECLARATION Job Description
i 5 I Mosby affirm Net I Am licensed under provisions of Chapter 9(commencing
iwith n ulto=andeeffaeDivlslan 3ofNe Business and Prafnalo.Code.AM mylkenec is l. ADDITION 598 ' -KITCHEN/REC RM/FAMILY RM/BEDRM #2
;jzqq ucenncl.a Lk.p
Data REMODEL BEDRM & BATHRM
W ARCHITECTS DECLARATION
I 77< I understand my plans awl M used As public rtaw
i U
GV; Licensed Preunienat
3
OWNER-BUILDERasemptDE Ce ContrON
i I krehy amrm Nol 1 am exempt from the Contractors License Law for the
p O (allowing moon.(Section 7031.7,Buamu and Profession,Cale:Any city or county
i$ which requires a permit to eomtruct.altar,improve,demolish,or repair any structure
•z priormitsWoman.AburequireslkapplicantforsuchpermittoOleasignedstatement Valu 1
Nat he is licensed pursuant ted previsions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area ®tP 8 O 2
1 $ (commenang with Section 7000)of Division 3 of the Business and Professions Cade)or
.. Net k u exempt therefran and due basis for Ne alleged exemption.Any I ol.don of
Section 7031.5 by A"Applicant I%A permit subjects the applicant w A civil penalty of APN Number Occupancy Type
am mom than raw hundred dabs 0071. 3 6 2 2 7 0 3 3 . 0 0
❑I..owms oftk preperty.mmy employes with wgnsa Neo sok eampe.adon,
will do Na work and theatrweam,is notlnteMod oroRered fornk(Sec.704/.Business Required Inspections
and Professions Cads The Commerce,Liam Law don tat apply w An owner of q P
propertywha bu(Idsarimprovn Nemon,andwha doessuchwarkhimselfarthrough he
own employees,provided Nn well Imp sero menu art not intended oroffered for sale.if,
however,the Wildinger improvement Is said within as Year,of amplMOn,the Owner-
builder will haw the burden of proving that M did not Wild or Improve far purpose of
sale.
1.As owner of the Property.am exeloomay containing with Ikevmacton ed ato
wtutmm the preject(Sec.7044,Businm AM PmfOW.Code:)TM COMMUO S Ll'
mem,Law don sot apply to An owMr of hopeny who builds or improves thereon.and.
who contracts for such projects with a contion er(s)licensed Wrawnt Le the Contractors
Us.law.
❑Ire exempt ndm Sea B d:P C for this maven
Owner Disse 7 1 6
\�WORKFRS COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury aro of the fallowing declantiaae
I lom and will maintain aCeniOase of Consent to self-inert for WarluesCompen-
sadon,as provided for by Section 3700 of the Labor Cade,for the perfemwa of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Imurma,As required by Section
3700o(Na Labor Cade,for the performance of the work for which this permit is issued.
My Workers Compensation Inmraece carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This senicomed at kcomplead if ted permit is fmam,hundred d AWA(SIM)
or Iw.)
1 anify that in dose performance of the work for which this permit is Wad.I shall not
employ anypersan in any.nm so As m become subject to tMWorker'CompenNan
Laws of Califomia,Data rfj&
NOTICE
Nbj CE W du
: s AfterCom waging the Cisions of of Exemption.you ushould
mot
Mrthwi h comp y the Wo oCampewtion provisions of Ne lab.Coda you mot
,J O forthwith comply with palm pmvelo.or Nu pewit shall M domed oswked.
CONSTRUCTION LENDING AGENCY
(.w IMreby afMn dust them isoa.tnanjon lending agency for do ismfomana of
fat> Use work for which the permit is issued(Sec.3097.Civ,C.)
Wit 0 Lenders Name '
Leaders Addmn
U Q 1 comfy that I haw mad this application and mm that the above Information is
t7+P comet.I agree w comply with all city and county ordinances and state laws misting to
0U building convection,AM hereby mNmm eproentatiws,(this city to enter upon the
W abovomcmiunsed property far inspection purposes.
G (We)Agree to saw.indc rally and keep h4mlesa the City of Cupcnina Ag4imt
Cn liabilities,judgments.cam and expenses which may In my ray 4c.q4=1 Me City
u Z in coesogeance of the granting of the parol.
APP TCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE RECUWTI NS.
?4 r lo 6 Re-roofs
Si rtofApplicArVContmcwr Dam a of Roof
HAZARDOUS MATERIALS DISCLOSURE lyp
Ill due applicant m future wilding nescupant atom orkndle havmda.material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cade,Section25532(07 wAll roofs shall be inspected prior to any roofing material being installed.
Yes a
Vin ted applicant m future Wilding aavpant tax equipment m&AFk I which If a roof is installed without first obtaining an inspection,l agree to remove
It human.Air contemi.m As dofircd by the Bay Arta Air QuAlity Management all new materials for inspection.
DiwittT �
❑Yea Yp Nu
I have mad the hamedwo materials requirements under Chapanti.9Safthe Califon
nia HaaM&Safety COM,Se =25505,23333md25534.1undcntand Neti(thc Wilding
does not cuml haw A tenant,that It a my rnPossibility w Redly it.occupant Of the
requiremenuwhm=bcmipfiarwinuanaof&C=nuwo(Ocppmq Signature of Applicant Date
a"' All roof coverings to be Class "B"or better
Owecraranth 7 agent Dam'