04030028 ZTAPT.P.71
NO
N PERMIT � CONTRACTORINFORMATIONy�
VT CONSTRUCTION PERMIT NO.04030028
PERMIT I SUE DATE
AN
E: SANITARY NO., CONTROL NO.
408
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Qsa o
LOQ LICENSED CONTRACTOR'S DECLARATION Job Description
>; C I hereby affirm that 1 am licensed under provisions of Chapter 9(eammewing
�Zw with Section'!")of Division 3o he Business and Professions Cook.aM my li«vc is
nfanto=and effect. KITCHEN REMODEL JUN 9 2004
.>jZ License Class Lic.N
n qFq p Dam Contractor
'tam ATION
1 understand my plans shall be used in public remrrds
BUILDING
G
3u. Licensed Professional
5 OWNER-BUILDER DECLARATION
I hereby
affirm that 1 am exempt from the Coulaachir's License Law for the
O o following meson.(Section 1131.5,Business and Professions Code:Any city.,county
K m which inquires a Permit in construct,slier,improve,demolish,or repair any structure
poor it)its inumm,also Ryui¢S the applicant for such permit to file a Signed somal 0l
that he is licensed pursuanunthepmvisionsafthe Conuacmr'iLicense Law(Chapter 9 Sq. FL Floor Area Valuation
y�m (commencing with section 7")of Division 3 of the Business and Professions Code)or
i $ that he At exempt thcefrom and the baso fm She allegad exemption.Any violation of
section 7031.5 by airy applicant for a Permit subjects the applicant o a civil penalty of 3 W`617,0ifter00 Occupancy Type
not mom th n RK hundred dollars(M).
❑I,As owner of the property,or my cmploycu with wages as their sole compensation,
will do the work,and the machine is not intended or offered for sole(S«.7014,Business
And Professions Code:The Contractors License Law does not apply to An owner of Required Inspections
property who builds or improrma Neuron,and who docs such work himself or hough his
Own employers,provided thin such improvements art not intended oraffered for We.If.
however.the building or improvement is sold within arm year of completion,the owner.
builder will have the Isr lm of proving that W did not build or improve for purpose of
We. i
1,as mater of he progeny,am exclusively contracting with licensed conummrs to
osuuct the project(Sec.7061,Business and Professions Code)The Conusemr's Li.
cense law does not apply m an owner of property who Wilds or improves heron.And
who concocts for such projects with a cottontails)licansed pursuant to the Connector's
License law.
1 em examggq��i under «. B&P C far this Raman
L tv' '`'X Dam t�
WORKER'S COMPENS ON DEC�IA/q/ATIO
1 hereby affirm under penalty of perjury ane ofMlThRawing declarations:
have and will maintain a Cenificam of Consent to adf-insum for Works'Condition.
Anion,As provided far by Section 3700 of the Latin,Code.far he pmomence of the
work for which this Permit is issued.
❑1 ban And will maintain Wcrkeis Compensation Inmrance,As required by Section
37Wof the labor Cook,for the perfounnm of the work for which this permit is issued.
My Worketm Compensation Insurarme carrim And Policy number all:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section wed not bocompleed if the permit A future hundred dollars(SIM)
less)
1 certify that in the performance of the work far which this Permit is issued.I shall not
employ any person in any mariner so AS to Wcome subject o he Worimm Compensation
Laws of California.Date
Appliesm
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
become subj«t m the Workers Compensation provisions of the labor Code,you must
0z foMwith comply with such Provisions ter his Permit shall be doomed mvaked.
Z2 CONSTRUCTION LENDING AGENCY
'e. 4 I hereby affirm that pert is a construction lending ageacy for the perforrnane,of
C'7 dm work for which this permit is issued(S«.309E Civ.C.)
W A lender's Name
6v Lender's Address
VC) I certify that I have Rad this application and muss that the above information is
ly P cortect.I agree m comply with 41 city and county asdinnas and sum laws relating to
0 U Wilding construction.rad hereby mdorire epoesenuuves of this city to enter upon the:
,r W above-mentimod property far icap«Vmn p.q.
liabilities.j)dagree
ent.cAovseis end�.ar.,whicclhm harmlessy and keep oAny wayr... gains,said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE GU TIONS, rf/
} a Re-roofs
rgnaturt fApplrc NtrAZARDOUS MATERIALS DISCLOSUR Date Type of Roof
Will he,applicant or future Wilding arupant nom w handle hamNaus material
defined by he Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
c,Section25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
p Yes )l Nu
Will he applicant or fuhm building Occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I haAMaus air conuminnts defined by hm Bay Arta Air Quality Management all new materials for inspection.
DihicL9
❑Yes �u
I have mail doh ardo���usSSSmalerialarequiRmcnu under Chaper6.95ofhcCalifor-
nia Hcalth&Saf ty COdc,Sections 25505.25533 and 25534.1 understand We if he Wilding
dors not currently have a tenant that in is my responsibility to nouly the«euput of the
requirements which mast W met prior to issuance oft Ceufmate facts army. Signature of Applicant Date
DaAll roof coverings to be Class"B"or better
GaneorauNori'rmd agent m