03080060L Y VN' C:UPEKIINU r A
BUILDING DIVISION PERMIT
?ING ADDRESS: CUPERT INO KITCHEN DESIGNS PERMIT NO03080060
OWNER'S NAME:
PHONE:
O O LICENSED CONTRACTOR'S DECLARATION
lj P 1 hereby affirm (hat f am licensed under provisions of Chapter 9 (commencing
a aU% with Section 7000) of Division 3 of the Business +d Professions Code, and my license is
Oma, in fullCorc an clfe•t. ,/�.6rAQ �J -2-
z L[ccnsc CI I L' Lic. N
F p ate '� " Cuntractore LSU
„W.( ARCHITECTS DEC64RAI'ION rG � n1
2" -It 1 understand my plans shall be used as public records!
b a O b aQcji,
WO II Licensed Professional
ti OWNER -BUILDER DECLARATION
<� 1 hereby affirm that I am exempt from the Contractor's License Law for the
OO following reason. (Section 7031.5, Business and Professions Code: Any city or county
<m which requires a permit to construct, alter, improve, demolish, or repair'any structure
.z y, prior to its issuance, also requires the applicant for such permit to Glc a signed statement
2 0 that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
t- (commencing with Section 7000) of Division 3 of the Business and Professions Cn�c) or
u $ 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 of
not more than five hundred dollars ($500).
❑ 1, as owner or the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The'Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work himself or through his
own employees, provided that such improvements are not intended oroffered forsale. If,
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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
cense Law docs not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
C3 am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My orker's Compensation insurance carrier and Policy number are:
er:Af — FUIQID �yNo..0001•O-lU—ZQ03
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the -work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of•Excmption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
.J z forthwith comply with such provisions or this permit shall be deemed revoked.
0
z
CONSTRUCTION LENDING AGENCY
(-+ � I hereby affirm that there is a construction lending agency for the performance of
Ri the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lender's Name
ZLender's Address
U O, 1 certify that 1 have read this application and state that the above information is
w r• -r correct. 1 agree to comply with all city and county ordinances and state laws relating to
Q U building construction, and hereby authorize representatives of this city to enter upon the
W ahove-mentioned property for inspection purposes.
�y (We) agree to save, indemnify and keep harmless the City of Cupertino against
H liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of [his permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO RCEREGULA tEl S,
Date
HAZARDOUS MATERIALS DISCLOSURE
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
Cod a,
Section 25532(a)?
❑ Yes f 0 No
Will the applicant orfuture building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District.
C] Yes ❑3u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code, Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsib' 't to notify the occupant of the
-/,)&
Owner
Owner or authorized aeenl Datc
10562 S DE ANZA BLV
408)257-4900
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
BATHROOM UPGRADE (3).
Sq. Ft. Floor Area Valuation
32616058.00
APN Number Occupancy Type
102
103
1'04
105
106
202
203
204
205
301
302
303
304
305
306
307
308
309
310
311
313
501
502
503
504
505
506
507
I
Issued by:5
Re -roofs
Type of Roof
r uulvLJ.c-'kehhdiAd Inspections
- PIERS
- UFER
- REBAR
- ANCHOR BOLTS'
- SEWER & WATER
- UNDERFLOOR PLUMBING
- UNDERFLOOR MECHANICAL
- UNDERFLOOR FRAME
- UNDERFLOOR INSULATION
- ROUGH PLUMBING
- TUB & OR SHOWER
- ROUGH MECHANICAL
- ROUGH ELECTRICAL
- FRAME
- HOLDOWNS
- INSULATION
- SHEETROCK
- EXTERIOR LATH
- INTERIOR LATH
SCRATCH COAT
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
- FINAL PLUMBING ENERGY
- FINAL MECHANICAL ENERGY
- FINAL BUILDING ENERGY
FINAL ELECTRICAL
- GAS TEST
- FINAL PLUMBING
FINAL MECHANICAL
FIN
NG 2
C WORKS Date /
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better