05010060 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC F0W1NT09MATI0N
UIL II pRr OXLEY WORKS PERMITNOO5010060
W NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. .. CONTROL NO,
(408) 838-6941
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Op LICENSED CON RACrO 'S LARATION Job DesCrl [1 O
�NE1 h IF affirm that 1 em licensed under mons of CMPter 9(commencing PALW
zl� wtlpe 3cc' '>(NN))uf Di ision3 ofthc Busin' anJ Prufcssinns Gulc.end mylic<nu is
int and a. REMODEL KITCHEN/BATHRM (1)
)12Z Lie m Class Lie,a
o Data GrnoE.CL FEB l6 2005
p'aJ RCHITECTS DECLA A O
f`oto'a.U tanJ my plans shall M vud TltuWv.rvssvda� may,p pp ffDss��k aB
e G G Licensed Professional s A / IL.P U I L
g OWNER-BUILDER DECLARATION ® YY
s y 1 hereby corns that I am exempt tram the Contractor's License Law for the
00 following reason.(Section 703 1.5.Business and Profession s Cade:Any city or county
m which myuins a permit m construct,alter,improve,demolish,or repair any.stmctum
prior to its issuance,also martins the applicant for such permit o file a signed statement .18000
that tic is liccomad pursuant to the provisions of the Contractor's 1-tocna,Low(Clupoer 9 Sq.Ft. Floor Area Valuation
e t-$ (commencing with Section 7")of Division 3 of the Business and Professions Code)of
that M u exempt utertfmm and me baso for Bre alleged exemption.Any violation of
Section 1031.5 by say applicant for a permit subjects the applicant to a civil penalty of 3 1AfflBI20&16er00 Occupancy Type
not more tan five hunartddollars(SSW). P Y YP
❑1,as owner of the pmperry,m my employcu with wages as their sole compensation,
will do the work,end tM sweturt isnot intended or offered for sale(Sec.1044,Business
and Profcimons Code:The Contractors Lianas Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who docs such work himself or through his
tun employees,provided that such improvements are not intended oraffered for sale.It,
however.the building or improvement is sold within one year of completion,me owncr-
builder will ban the burden of proving ton he did not build or improve for propose of
sale.).
❑ I.as owner of the propeny,am exclusively contracting with licensed conuanors to
construct the project(Sec.7044,Bus nems and Professions Code:)TM Corusetori Li .
een a law does not apply to an owner of property who Wilds or improses Marton.and
who contracts for such projecu with a conmetor(s)licensed pursuant to de,Convector's
Law.
exempt under Sec. .B&P C for this moon
Owner
Data
WORKER'S COMPENSATION DECLARATION
1 hereby afRmt under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for WorkeraCompen-
moom,u provided for by Section 3]00 of the Labor Code.for me performance of the .
work for which this Permit is issued. -
❑1 Mae and will maintain Wrrkcfs Compensation tIn(svrarnc,u rtyuirtd by Section
J100 is me labor CMe,for the pcefofntanee of me work fpr which this permit is issued.
My Workers Cnmfan et ion lnxurtna cvricr and 1'y umber am:
Cartier: Poli
CE IFlCAlEOF E%EMITfO& OMWORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the Permit is for one hundred dollars(SLOG)
or less.)
1 ceftlfvtM1arm,c pct Once of Bic work for which this Permit u issued.1 shall not
-.opo,
mPmy A) so ' any ma cryo ubjccuo lc Workeri(',ymponsatiom
auf Cehf on Date
Ap
N CE TO APPLICA :Ir.after making this mircam of Exemption.you should
me subject aro the Worker's Comfamation provisions of the Labor CMG,you mum
Oorthwith comply with such provisions or this farm it shall be deemed mvokcd.
Z� CONSTRUCTION LENDING AGENCY
I Msby Mo.mat mete isa cosntfuction lending agency for tM Performance of
].' > the work for which this pnmit is isvucd(Sce.3091,Civ.C.)
i1 Q Lender's Name
7 z Lcndcr's Add.
:) 1 modify that I have read this application and state that the above information is
yy f^ torted.l agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize rcpresentatims of Otis city to enter upon the
abovomcntioncd property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino agaima
faj3 liabilities,judgmenq costs and expenses which may in any way acc me against said City
J z in consequence of the granting of this Permit
.APPLE UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S EREG ATIONS.
�_, -C6 Re-roofs
gnatur aHAZARDOUSMATERIA 'DISCLOSURE CLOSURE. 'Dart Type of Roof
Will for,applicant or future building Occupant nom or handle Mrzrdous material
efinM by Be Cupertino Muniei 1 Cook,Chapter 9.11,end the Heals and Safety
.section 25532(a)1
❑Ycs Nu All roofs shall be inspected prior to any roofing material being installed.
Wal mea licant or future building oar ane nae a If a roof is installed without first obtaining an inspection,I agree to remove
PP s v yuipmem or Jcvicu which g
it haiardnus air contaminants ms Jarrod by the Bay Arca Air Quality Management all new materials for inspection.
DuvicR
❑Ycs
rhiivcocaxlrhelkmoas amaterials myvirtmenu untkr ChaPter6Y5 ofd¢Califnr
nalto& M,Seniou 155J3and15534.1unk.wdmwifmchvilding
snot curer 1,M1 O rens thm it' y rex sihiliry lea notilj Ibc aacuPart of the
re i �ntswbe, um lx etPripfa ,aaneeoaecmrtifieateorQ:eppmey. Signature of Applicant Date
tuner Or authoriscJ ages am
All roof coverings to be Class "B"or better