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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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CG��iTICMOTUR I .1,109
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IND IM`T
BUILDING ADDRESS:`WELKININTERNATIONAL
"GO 3 0 5 0 0 3 5
1
OWNER'S NAME:
19,925 STEVENS CREEK BLVD
"'iMn 8/ 2 0 0 3
(408)252-3396
SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
'
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
. -
with Section 7011(1) of Division 3 of the Business and Professions Code, and my license is
,
and effect.
L
KITCHEN REMODEL/UPGRADE
en eClassforce
License Class Lic. ri
,Date Contractor
ARCHITECTS DECLARATION
,
I understand my plans shall be used as public records
.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
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 forsuch permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter9
Sq. Ft.
Floor Area
$17%i8tion
(commencing with Section 7000) of Division 3 of the Business end Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 @XNB>�er0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
—
d Inspections
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
Professions Code: Contractor's License Law does to
and The not apply an owner of
10 2
— PIERS
property who builds or improves thereon, and who docs such work himself or through his
own employees, provided that such improvements are not intended orolfered for sale, If,
10 3
— UFER
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
104.
- REBAR '
sale')'
105
- ANCHOR BOLTS
kI, as owner of the property, am exclusively contracting with licensed contractors to
10 6 -
— SEWER & WATER
conswct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and ,
202
- UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law. --
203
- UNDERFLOOR MECHANICAL
❑ 1 am ex nfipt oder Sec. B & PC for this reason
/
204
- UNDERFLOOR FRAME
tSwn�r Da J�
205
- UNDERFLOOR INSULATION
L/ RKEk'S' eI61PE SATION IkECDNATIQ ✓
301
— ROUGH PLUMBING
I hereby affirm under penalty of perjury one of the following declarations:
-will
3 02
— TUB & OR SHOWER
C] Ihave and maintain aCertificatcofConsenttoself--insure for WorkersCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303
— ROUGH MECHANICAL
work forwhiehthispermitisissued.
304
— ROUGH ELECTRICAL
C1 1 have and will maintain Worker's Compensation Insurance, as required by Section
3 05
FRAME
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 arc:
306
— HOLDOWNS
Carrier- 4 Policy No.:
307
— INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
308
- SHEETROCK
(This section need not be completed ifihePermit isfor one hundred dollars (5100)
309
- EXTERIOR LATH
or less.)
310
— INTERIOR LATH
I certify that in the performance of the work for which this permit is issued, l shall not
employ any person in any manner so as m become subject to the Workers Compensation
311
— SCRATCH COAT
Laws of California. Date
Applicant
313
501
— ROOF NAIL
- 'FINAL ELECTRICAL ENERGY
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
forthwith comply with such provisions or this permit shall be deemed revoked.
'502
— FINAL PLUMBING ENERGY
503
— FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
504
- F I NAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
505
506
- FINAL ELECTRICAL
— GAS TEST
Lender's Address
1 certify that 1 have read this application and state that the above information is
507
- F I NAL PLUMBING
correct. 1 agree to comply with all city and county ordinances and slate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
F I NA ME CHAN CAL
shove -mentioned property for inspection purposes.
Q 9
FIN -
(We) agree to save, indemnify and keep harmless the City of Cupertino against
C
liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequ5n9e of the granting of this permit.
' APPLICrC UNDERSTAN AND WIL C PLY WITH ALL NON -POINT
5
Issued by.51
I G `j
WORKS Date
SOU
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
Yes
All roofs shall be inspected prior to any roofing material being installed.
❑ �Nu
'
If a roof 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 az defined by the Bay Area Air Quality Management
all new materials
for inspection.
District?
[3 Yes Nu
I have read the hazy ous materials requirements under Chapter 6.95 of the Califor-
niaHealth �PrSatctyCodc, Sections 25505,25533 25534.Iunderstand that ifthe building
does it is
6 cugently ham a tens at my ros onsibility to notify the occupant of the
requ
�- J
Signature of Applicant
Date
All roof coverings to be Class "13 or better
Cr
or authorized ageni Date