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I'T'Y OF CU13ERTINOBUILDING
DIVISION PERMIT
CONTRACTOR INFORMATION
FBUI
LDINGADDRESS:
K & M DEVELOPMENT INC
PERMIT1003080099
:R'S NAME:
1060 WEST HILL CT
PERMIT ISSUE DATE
"Et
(408) 253-9787
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section ]IXN)) of Division ] of Um Busjq¢a+and Profcssinna Codc, and my liccuc is
in full fo rad cfrec �"
Li«nye %3 L a / �' /
DEMO
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OW - ILDER DEC RATION
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1 hereby affirm that I am e License Law for the
following remain. (Section ](131.5. Business and Professions Cade: Any city or county
which requires a Permit to conatruc, alter, improve. demolixh, or repair any suuclua
poor hr it%issuance, also requires the applicant for such permit to file a signed aemmen
that he is licensed pursuant to the provisions of the ContracLor's License Law (Chapter 9
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Sq. Ft. Floor Area Valuation
(commencing with section IDtp) of Division 3 of the Businass and Proreations Cade) Lir
that he is exempt therefrom and the basis far One: alleged exemption. Any violation of
32630058.00
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
APN Number
Occu ane -Type
not more than five hundred dollars ($500).
p y yp
E] 1. as owner of the progeny. or my employees with wages as their sole compensation,
will do the work, and the snort is not intended crancred for sale (Sce.]BU, Business
and Profession Cock: The Corunhu is License Law dors not apply to an owner or
_
Required Inspections
progeny who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements arc not intended or offered for sale. If.
however. Ne building or improvement is mid within ane year or completion, the owner.
.
builder will have the burden of proving Nat 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. 744, Business and Professions Code:) The Contracrerh Li.
�.
cense Law does Out.pply m an Owner or prapacity who builds to improves Ncreon. and
who contracts for such projects with a coneacor(s) licensed pursuanuo the Conrracm's
Lismram Law.
❑ 1 am eacmpt under Sec. B & P C for this reason
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WORKER'S COMPENSATION DECLARATION
1 hereby affirm under anally of perjury one of the following dedaretions:
I hove and will maintain a certificate or Consent to self-insum for Workers Com en.
lariat, as provided far by Section 3]40 of the labor Codc, for the performance of the
,
work for which this Permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
37W of the Labor Code, far the arformancc orthe �wprk for wbi<h ims permit is issued.
My Work nsu to 11 no
cY No.: zC
RTIFICA F EXan P l,f FROM WOR S
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred i nlims ($100)
of less.)
1 certify that in the Performance of the work for which this Permit is issued. I shall not
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employ any person u m m any manner so become subject the Workeni Compensation
Laws of California. Dore
Applicant
NOTICE TO APPLICANT: Ir, after making this Cenificam of Exemption, you should
became Subject Or the worker's Compensmion previsions of the labor Code, you must
forthwith comply with such provisions or his permit shall IN deemed mvoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency I'or the performance of
the work for which this permit is tamed (Sec. 3(19], Civ. C.1
Lender's Name
Lender's Address
I anify that 1 have read this application and sum that the above information is
mann. 1 agree to comply with all city and county oNinanee5 and state laws relating to
building Conswction. and hereby amhorim representatives of this city to enter upon the
above-mentioned pmpCny for IeSpe
(We) agree to save, indemnify end keep harmless the City of Cupertino against
expenses whichpurposes.
coati and exon... which may in any way accmc against City
in consequence of the
in eonmquenec of the gaming of this Permit.
APPLSOURICANT CE R[ UN TIONS NDS AND WILL COMPLY WITH DINT DINT
Issued by: Date
J� 29,3
Re -roofs
Signature —I Dz
AZ OUS MATERIALS DISCLOSURE
Type of Roof
Will c applicant Lir future building Occupant more or handle havamous material
'
dehned by the Cupertino Municipal Cock. Chapter 9.12. and the Health and Safety
. Scotian zss3z(a)]
Vcs
All roofs shall be inspected prior to any roofing material being installed.
I I
Will the applicant or future building occupant Liu equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
g p
it h4[ardnus or, cboo minants dcOned by Ne Bay Area Air Quality Management
all new materials for inspection.
mitt?
❑Yes Nu
I have mix] the hanothous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cabe, Redoes 25505.25533 and 8534.1 understand that if tR building
does not cwrtntly have a enure, that it is my responsibility m modify the occupant of the
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