05010123 CITY OF CUPGRTINO
BUILDING DIVISION PERMIT ' CONTRACTORnINFORMATION`
But LDING ADDRESS: KIA CONST. PERMIT N005010123
15 KENTWOOD AV
OW NER'S NAME: PERMIT LSSUE DATE
RODNEY BEAVERS 1775 CARDEL WAY C)1 /21 /2005
ONE: SANITARY NO. CONTROL NO.
(408) 978-6468
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C7 E t�
+00 LICENSED CONTRACTOR'S DECLARATION'
rc F❑ 1 hereby affirm that 1 am licensed under provish m of Chapter 9(commencing lob Description
f6W with Section 700(t)of Division)of the Basin.and Professions Code.and my license is
j�% in roReClessderren. REMODEL KITCHEN/NEW .APPLICANCES/RECE . LITS/
inifanurcea Lic.N
��o Date Contractor BRANCH CIRCUITS ty �f �ppseeeee
ARCHITECTS DECLARATION {7_ yy��
f w u 1 understand my plana Soso m Bud u public rtenrus Itlf�' O [,VB
y Licensed Professional
cpg OWNER-BUILDER DECLARATION {
P I humby affirm that I am exempt from the Conaactm's License Law for he MAY /� 2005
o fallowing mann.Section 7031.5.Business and Prefeaions Calc:Any city or county _
which motor.a permit to construct.alter.impmm.demolish,or repair any wmctare
0 prior to its issuance.31W rcquirca the applicant for such permit m file axigncdnmcmcnl EEE sfnwwr�oo
a that he is licensed pursuant to the previsions of me Contractor's Liccose Law(Chapter 9 Sq.FL Floor Area �� alU�(l�ip't.�OO
a (commencing with Section?")of Division 7 M the Business and Profusions Cade)or I (`jam','
mat he is exempt mcafrom and the basis for do,alleged exemption.Any violation of
Section]1171.5 by any applicant for a permit subjects the applicant to a civil Penalty Of ppN Number Occupancy Type
not more than fin hundred dollars(SSOB). P Y yP
❑ 1.a owner of the preperty,o my employees with wages a their sole eomlznsation, 35931013 . 00
will do the work,and me stmctute is not intended or offered for sale(Sea 90ba,Business
and Pmfasions Code:The Comescmr's Lt..Law docs not apply to an owner of Required Inspections
property who builds or improves theater,and who docs such work himselformmugh his -
Own employees,provided th a such improvements ree nut imanded oraRcred ferule.If.
however.me building or improvement is sold within one you of completion.the owner- -
builder will base the burden of proving that he did not Wild or improve for purpose of
sale.).
1.a Owner of the property,am exclusively contracting with licensed cremations to
concoct the preject(Sec.)o4a,Business and Prefasime,Code:)The Conuaztor's Li�
cert Law docs not apply to an owner of paonity who Wilds or improves thereon,and
who contracts for such protects with a contractor(s)licensed pursuant to Ute Contractor's
Latin Law.
I am exempt un der S B d:P C for this reason
13071W
eer .� Dam
WORK/E@/, 1P 5 TION DECLARATION
1 hcsby a1Rrm4ndG penalty of perjury me of tie following declasatiom:
1 have and will maintain a Certifcnte of Consent to self-insure for Worker's Compete
senior.is provided for by SCRian 37W of the Labor Code,for the perfmmanee of the
k for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,az required by Section
of me labor Code,for Js performance of the work for which this permit is issued.
Workers Compensation lnsunnee carrier and Policy number am:
Cartier: Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(Thu section need not teeompleled if the permit is fm ono hundred dollars(5100)
1 sanity that in the performance of the work for which Nis permit is isci I shall oat
employ any person in any manner Or u to become subjecuo the Worketd Compa¢aGon
Laws or California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cerificam of Exemption,you should
become subject to the Worker's Com pewtion provisions of the Lahm Code,you m u
,Z forthwith comply with such provisions or this Permit shall he deemed revoked.
Z'O
CON STRUCTI ON LENDING AGENCY -
1 hereby affirm that mere its concoction lending agency Ior the performance of
:4 me work for which this permit is issued(Sec.7097,Civ.C.)
31 QLenders Name
3.
7 z tender's Address
1[coley that 1 have read this application and sure that the above comtatinr is
y F bonding 1 ante to comply with all city and county oriinu,ces and Cote laws slating to
e
C.) hui,Cmootimmid.and heathyaomonfurdpresenmtives ofthisCity mcnterupon the
= a above-(We). me to .rind inspection purposes
(Wt)ag a to cast,indemnify and lith hay in an the City of cartoon.s against
N incoitxpracrdgmcntse costsandof this expenses which mayinanyway¢cmc against said City
J z A APPLICANT
of DERSTAN of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU�ti�yIONS.
\ l�¢�19-lV/�/a /—Z/-os Re-roofs
Signature- APPlicanVC6ntrraac Dao
/HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theirfi fano or future building Occupant tore or handle haiumoue material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cole.Scction 25572(x7? All roofs shall be inspected prior to an roofing material being C]Yes �(Na P P Y g g installed.
Will the,applicant fmuse building ac,u ant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
rap s p aAirQn
7Diurimtl
handouts air contaminants a JcOncJ by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes �7 NoIhavcatth&SafetyCode.SccuomM505,25577enJ2557d.lunJc dmwifmc Wilding
not eumemly haul a wnext Natitismyre.pWmihilitytonodlytt¢mcupamofme
iamcno ch Fbemctpriorla or,ednifaateofOccapiracy' _ Signature of Applicant - Date
/,' -?�'� All roof coverings to be Class "B" or better
erur utmenred I Date
V