04060120 CITY OF CUPERTINO ^F -%`$ Ares F '^"• " �' ° "fl "x'''�
BUILDING DIVISION PERMIT CONTRACTORMATI 0
BUILDING ADDRESS: PERMIT NO04 0 6 012 0
1140 KENTWOOD AV
OWNER'S NAME: PERMIT ISSUE DATE
DAFNA & RAN AVINUN
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
131.45611r, ELECT PLUMB MECH
0 0
°00 LICENSED CONIRACfOR'S DECLARATION Job DOSCTIpt1O0 B A
m I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing
iW with Scream 70ou)ofDivision Sof NC Business and Pmfessams Cods.rud my licensors
in full force and effect. tA a�R
j�? License class Li.. ADD 367 BEDROOM/BATHROOM ryr
L`'o9 Dam cpmramr REMODEL 2 BATHROOMS
1'� ARCHITECTS DECLARATION ftxo/I underwnJ my plans shall be used u public mcnrm J
o� Licensed Pnucssional
S OWNER-BUILDER DEC.C.fir DN
I hmroo affirm that 1 vat exempt from the Cnnions Co :Any c taw fou the A
1 p o following mann.(Section II13 construct.
Business and improve
detinet Code:Any city m cpamy
m� which mquiru a e.also pa cams the encu,nt for
h famms t file
repair ed swnum
FZa privru its lensed pursuant
10 the the of for suchmon's License Law(Cha mem
mm tMtMislicensedpursuammthepmvimonsnfthe Comracmr'.Licenulaw(CM1eper9 Sq. Ft. Floor Area Valurigt'ygTI00O
m (commencing with Sectio 7000)of Division 3 of the Business and Profusions Calc)or
W. Nat he Or cxcmpt durefmm and the basis for Ne alleged exemption.Any violation of
Section 7011.5 by any applicant for a permit subjects de applicant o a civil penalty of APN Number Occupancy Type
not mom in.five hundred dmlara(5500). 35931053 . 00
1,as owner of the progeny,or my employees with wages u their sole compensation,
willdathework,andua ...lure is notintended oroffered for sale(Ser.104,1,Business
and professions Cade:The Comactor's License Law does Mt apply in an owner of Required Inspections
prop try who builds orimpmms thereon,and whodmssoch work himselfor through his
mon emplaycu,provided that such improvements art not intended orolTesed for sale If.
however,Be,building or improvement is sold within one year of compleuon,the owner-
builder will have the,burden of proving that he did not build or improve for purpose of
sale.).
I.as owner of tM proper,am exclusively contracting with Iicamed contractors u
construct the project(Sec.7044.Business and Professions Code:)The Conuacmr's Li
come Law does not apply to an owner of proper who Wilds or improves,daemon,and
who commour for such projects wit a contractor(s)licensed pursuant to Be Cmume ofs
License law. rrII
p lam in Sec. //�tT ,B&PCfor u )u�saa
O a WORKER'S COMPI�E~TION DECLARN-11t,
expe— I 07
1 Mmby shore under pantry of perjury one of Je following declarations:
1
in and will maintain a Ccruficate of Conant to self-insure for Worim'sCompcn-
sasion,as provided for by Section 37W of the Labor Code.for the performmec of the
work for which Nis permit is issued.
I have and will maintain Winter's Compcmation Imuraoce,as mquimd by Section
37W of t e labor Cade,for Bm peRormance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number me:
Corea: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(bisection need not M.omplemd irthe permit is for one hundred dollars($100)
less.)
1 certify that in the performance of he work for which this permit is issued,l shall not
employ,any potion in any manner m sum become subject o the Wofkers'Compersainu n
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Ccnifieare of Exemption,you should
become subject to the Worker's Compensasivn provisions of the Labor Code,you must
Z forthwith comply with such from mons of Nis permit shall to doomed revoked.
ZO CONSTRUCTION LENDING AGENCY
[-+ Ihcmby affirm that there is a conmmnim lending agency lot the Performance of
t(L work for which this permit is issued(Sec.3041.Civ.C.)
L1]Q lender's Name
Le
D l.ndcidrrss
Lender's Ad
U Q I cenify that 1 have Icad this application and sure that the above informal..is
corrtm.l agree to comply with all city and county on inances and sure laws relating to
U movcng ntionection,and forcbYauthonprmoses. di cs of this city to corer upon the
Y'tg3 aMve(We)agree
morally for a keep h
(We)agree a arc,indemnify and keep harmless the City of raCupcnsta against
UZ in consequence
of the graciosix ng expenses which may in any wayaecme against City
U^ APPLICANTOUNDERSTANDSof dhis ANDrWILL COMPLY WITH ALL POINT Issued by: Da e
SOU RE ULATIONS. I _/T—
Re-roofs
S� urcof pplicant/Contnaor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building Occupant stem Or handle havarduus material
as defined by Be Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Cedric.s..ues zsslz(aYn All roofs shall be inspected prior to an roofing material being Installed.
❑Ye, dNu P P Y g g
Will the applicant or future building Occupant tic equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
. o Meafdnus air mnumimnts u def
by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes [�No
1 have mad the h rommus materials requirements under Chapter 6.95 of the Califon
nia Halle&Safety Col,.Semom 255(15,25533 and 255]f4.1 undersrarel Who if the building
Joys not currently hmc a mmol.Our it is my responsibility in comfy the occupant of one
mmmme h u.home(Prinruissuance Of.cerufna,dGerman lU4 Signature of Applicant Date
Ati'_ II
Q.6'or mor.ri] agent naso All roof coverings to be Class"B" or better