08040175CITY OF.CUPERTINO
xs+ Yeaz arm
BUILDING DIVISION PEBNM"49,
Buf 6 'IN,*I FFORD DR
TBD — TO BE DETERMINED
Mrr NO.
P�08040175
OWNER'S NAME:
PERMIT BEIDE DATE
04/24/2008
PHONE
SANITARY NO, CONTROL NO.
ARcrmEC-MENGINEFx
PERMIT
REMODEL & RE—INSTALL KITCHE BLDG SELECT
PLUMG B MECH
LICENSED CONIRACIOR'S DECLARA71ON
I hereby aMran that I are licensed under provisions of Chapter 9 (commencing
-- .^ "_• T ^"'—• •^ ^' '^••^• • -�®b-I�eSCLi On.
with Secdoat 7000) of Division 3 of dee Business and Professions; Code, and my license is
in full force and elf tr
Ig 4 0 1�.
License Class _ Lie. N T `
.
Date Contractor
ARCHITECI-s DECLARATION
1 u - d�nyiplana sh used as public records
�'�Ctl(be
Licensed Profcssio al
OWNER -BUILDER DECLARATION
I bcrcby affirm that 1 am exempt from the Contractors LJcenu Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
-
whieh requires a permit to tanse•oct, alter: improve, demolish, or repair any suvetum
prior to its issuance, also requires the applicant for such permit to file a signed sutoment
that he is licensed pursuant to the previsions of the Contractors LJccnse Law (Chaptcr 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt therefrom and the basis for the alleged exemption Any vloladon of
Section 70315 by any applicant for a permit subjects the applicant to a Civil penalty of
APN Number
Occupancy �I
P
not more than five hundred dollars (5500).
Y •JPe
❑ L as owner of the property, or my employees with wages as their sole compeandon,
will do the wort and the maure is not intended or offered for sale (Sec. 7044, Business
and Professions Codc The Contractors License Law des not apply to an owner of
Required Inspections
property who builds orimpmvrs thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale It
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
sak.)
❑ L as owner of Elie property, am exclusively contracting with licensed contractors to
coast= the project (Sec 7044, Business and Professions Code:) The Cottranees Li -
erre Law does not apply to an owner of property who holds or improves thereon, and .
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law,
'
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I haft and will maintain a Cerdfiate of Consent to self -insure for Worker's Compen.
sadm n provided for by Section 3700 of the Labor Code, far the performance of the
Mame for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700*of the Labor Code, for the performance of the work for which this permit is (sued.
'
My Workers Comyp�nsation Insurance carrier and Policy number am:
Carrier. /' Policy No.
CERTIFICATE OF EKEMFTION FROM WORKERS'
COMPENSATION INSURANCE
((his saegon need not be completed if the permh is forone hundred dollars (5100)
or Iesa)
1 coolly that N the performance ofthe ork for which this permit is issued, 1 shall not
employ any Iverson in any rt!%Pr, ecome subject to the workers' Compensadon
Laws of California Duo
Appliam
NOTICE TO APPLICANT: lf,m 'ng this Certifcam of Exemption, you should
become subject to the Worker's 'tion provisions of the Labor Code, you must
forthwith comply with such provisions or this permit Shan be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is it construction lending agency for the performance of
the work for which this permit Is issued (Sc c. 3097, Civ. C)
Lenders Name
Lender's Address
'
I certify that I have read this application and sore that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building concoction, and hereby authorize repiesenudves of this city to at" upon dvc
above -motioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, c posses which may its any way accrue against said City
in consequence of the granting
APPLICANT UNDERST SIL COMPLY WITH ALL NON -POINT
Issued by: Date c
S � ��_
SOURCEREGULN
_-2
Re -roofs
Signatrus of Applit9rnVCon r Date
. O TERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code Chapter 9.17, and the Health and Safcty
Code, Section 75532(a)7
r-] Yes �lJo
All roofs shall be inspected nor to an roofing material beim Installed.
P P- Y g g
If a roof is installed without first obtainingan inspection, I agree to remove
P
Will the applicant or forum building occupant use equipment or deices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hearth & Safety Codc, Sections 75505.75533 and 75534. I understand ihat if the building
docs not currently have a ==L. that it is my responsJbility to notify the oesupanL of the
requirements of a Certificate of anry. '
Signature of Ac t Date
srpe
ZAll
t 1?
roof coverings o be Class 11� " or better
g
Owner or authorized sig Date '