08040223CITY OF CUPERTINO
BUILDING DIVISION PERMIT
x 3 3
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BUIL.TTjv TESAAN
MIT NO.
P�08040223
JUAN RD
TBD — TO BE DETERMINED
04/30/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHI ECTIENGINEER
REMODEL EXISTING KITCHEN &
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o a o 0
LICENSED CONTRACTOR'S DECLARATION
Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
--_ _ _ _ _,.--,,, ,.. ,.,. �� _..Job
with Section 70(10) of Division 3 of the Business and Professions Code, and my licerm is
In full fora and effect
Ucenm Cass Lic. 0
Date Contractor
ARCHrrECrS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I berchy 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, dcmolisb, or repair any structure
prior to its issuance, also requires the applicant for such permit to fik a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Pmfcssions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant e a civil penalty of
not more than five hundred dollars (s5w0
❑ L as owner of the property. or my employees with wages as their sole compensation,
Required Inspections
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 does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. 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
sak )
owner of the property. am exclusively contracting with licensed conuacrors to
corlauw the project (Sec. 7044. Business and Professions Code:) The Contractors Li -
cease Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such fees with a co tors) licensed pursuant to the Contractors
License Law.
❑ 1
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain ■ Certificate of Consent to self -insure for Workers Cornpew
Won, 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 Workers Compensation inmrsna, as required by Section
3700 of the Labor Code, for the performance of the wok for which this permit is issued
'
My Workers Compensation Insurance carrier and Policy number are:
Cartier, Policy No.:
-EXEMPTION
CERTiRCATE OF FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit Is for one hundred dollars ($100)
or less)
k for which this permit is issued, I shall not
1 certify that In the ce f�
Appilant
Ndnc L.ICAw',. f, after m ng this certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemby affirm that there is a cort uwdon lending agency for the pmformancc or
the work for which this permit is Issued (See. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have read this application and state that the above Infomtadun is
correct I agree to comply with all city and county ordinances and state laws relating to
building cmumnuction, and hereby audwrize representatives of thin city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino ■galnsr
liabilities, jodgtnens, costs and expenses which may In any way accrue against said City
in
f WILL COMPLY WITH ALL NON -POINT
A PLICCA
Date
MUARDOUS MATERIALS DISCLOSURE
W111 the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code ,Scction25532(a)7
❑ Yes
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
Will the applicant or future building occupant use equipment or dcviccs which
colt hazardous air contaminants as defy d by the Bay Area Air Quality Management
Dis rict7
all new materials for inspection.
❑ Yes No
under Chapter 6.95 of the Caiifor-
1 have
'rota pancy.
`5��
Signature of Applicant Date
u
All roof coverings to be Class '%{" or better
comer orarized t Dare