08100126CITY OF CUPERTINO
BUILDING DIVISION PERMIN__I�
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BurL.TW9T'R'ODRIGUES AVE
CUPERTINO KITCHEN+ DESIGNS
PERMIT NO.
08100126
OWNER'S NAME:
PERMIT ISSUE DATE
10562 S DE ANZA BLVD
10/20/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)257-4900
ARCH1T fSNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm war 1 w licensed under provisions on(commencing
with Section 7000) of Division 3 of Ile Buainm and Professions CodcCode.. and my license is
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N full force and effef3o 6
License f'aad Lie. >f
Date i Contraebr
i5el
ARCHT[ELTS D ON
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License�Pmfesfl'o— nom^
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from ibe Contractor's License Low for the
following reason. (Section 7031-5, Business and Professions Code: Any city or county
which requires a permit to comtlnc4 alter, improve, demolish, or rely any n^M°•T
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions of the
(commencing Section 7000) Division 3 of we Business Profession"Code) -
$15000
with of and
that he is esmtpt therefrom and the basis for the alleged exemption. Any violation of
3 6 9 0 4 0 4 3. °ice Number
Occupancy
P Y T YPe
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than Live hundred dollars (S500).
0 L as owner of the property. or my employees with wages u their sole compensation,
Required Inspections
will do the work, and The structure isrot intended oroffered for ink (Sm 7044,Business
and Professions Cade: The Commutes License Law dors not apply to an owner of
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property who builds or improves thereon, and who does such wort himself or through him
own employers, provided that such improvements are not intended or offered for sda 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
ask.).
0 1. as owner of the property. am exclusively contracting with licensed convectors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors li-
cense Law does not apply to an owner of property who builds or improves thereon, anti.
who contacts for such projects with a contractor(s) licensed pursuant to the Centracmes
License Law.
0 I am exempt ander Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Warkees Compen.
sation, as provided for by Section 3700 of the Labor Code. for the performance of the
wort for which this permit is issued.
K and will maintain Worker's Compensation Insurance, u required by Section
of the Labor Code, for de performance of the wort for which this permit is issued
'
My Worker's Compensation Insurance carrier and Policy number am:
Carrier _6ar�'^� Policy No.: Y06 it 10 ZbO iii
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic hundred dollars ($100)
or less.)
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' Compensallon
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 Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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.)
-
L.ender's Name
Lender's Address
I certify that I have read this application and state that the above information is
'
correct. I agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
ahove-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costa and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
Dag
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle banrdous material
as damned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Sectio0YeeSn25532(a)? ire
All roofs shall be inspected prior to any roofing material being installed.
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 materials for inspection.
District?
0 Yes Irl'No
I have mad the hazardous maerfals requirements under Chapter 6.95 of the Califor-
nia Health & SaferyCodc, Sections 25505, 25533 and 25534.1 understand thatif the building
does riot currently have a tenant, that it is my responsibility to notify the Occupant of the
rcquitemems which must be met prior to issuance of a Certificate of Occupancy,
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Signature of Applicant Date
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All roof coverings to a Classor better
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