07010045 CITY OF CUPERTINO
BUILDING DIVISION PERM-
PERMIT NO.
BUILDING ADDRESS: 01 QnA V,
1113 STAFFORD DR CABINET WORLD I PERMITLSSUEDATTs
OWNER'S NAME:
E'LNICK JACK D AND TATYANA A 1501 L1,UREL ST 01/08/2007
SANITARY NO. CONTROL NO.
PHU.": (650) 592-8020
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
z LICENSED CONTRACTOR'S DECLARATION Job Description
O
I hereby affirm that I amftd under provisions of Chapter 9(commencing KITCHEN REMODEL NO STRUCTURAL CHANGES
with Section 700())oCDivi' n 3 of the he Business and Professions Code,and my license is
y in full force and e v GLt��C2
z_ License Class �C Lic,
p
o Dae — Contractor
ARCHITECTS DECLA AT10N
I understand my plans shall he used as public records
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
OC following reason.(Section 7031.5,Business and Professions Code:Any city or county
li which requires a permit to construct,alter,improve,demolish,or repair any structure
} prior ui its issuance,also requires the applicant for such permit to file a signed statement —I;q.Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $18950
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of yp dumber Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 362
0 6 0 0 �7
not more than five hundred dollars(5500).
❑1,as owner of 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(See.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dors not apply to an owner or
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
sale.).
❑1,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.
❑I am exempt under Sec. B&P C for this reason
r , Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Ccrti6eate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insmaricc,.as required by Section _
3700 of the Labor Code,for the performance of the work for which_this_permit is issued.
My Worker's Compen 'on 1 ce carrier Policy number are:
Carrier. Policy No.:
CERTT OF ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date—.
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUC'T'ION LENDING AGENCY
rte.. I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
`~ Lender's Name
Z Lender's Address
C) I certify that I have read this application and state that the above information is
comm I agree to comply with all city and county ordinances and state laws relating to
U building construction.and hereby authorize representatives or this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
SOURCE REGULATE
M1yT� Re-roofs
Signatu or Appicant/Contracwr Dam Type Of Roof
MATERIALS DISCLOSURE yp
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
^-•tie,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes )!�No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
❑Yes Alla
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCodc,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenar that it is my responsibility to notify the occupant of the
��requimi which o suance of a Certificate or Occupant Signaturc;of Applicant Date
� �`—" —� All roof coverings to be Class"B" or better
Owner or authorized agent Date