05030190 CITY OF CUPERTINO `'
BUILDING DIVISION PERMIT CONTRACTOR INF,.ORMATION '
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BUILDING ADDRESS: PERMIT NO
CHRIS & WENDY YOUNG O5O3O19O
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHnECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 lY 0
,00 LICENSED CONTRACTOR'S DECLARATION
1 herby affirm that 1 am licensed under provisions of Chapter 9(commeuing Job Description
with Section70M)of Division]of the Business mod professions,Code.and my license is
s in roll forte and effete
ti'q? ueenxaas, Lic.g REMODEL KITCHEN & BATHRM
rat❑ DateContractor
q ARCHITECTS DECLARATION
aZ I understand my plans shall he used as public records
o Licensed Professional
5 OWNER-BUILDER DECLARATION
i f I hereby affirm that 1 am exempt from the Conuactors License Law for the
o O following meson.(Sation 7031.5,Business and Professions Code:Any city or county
$K which.quires a prow t in construct,.1im.improve,demolish,or¢pair any structure
s-zto prior to u
its issuance,also respires the applicant for such permit o File a signed statement
that he is;licensed pursuant to the provisions of me Convectors UcOnse Law(Chapter 9 Sq.Ft. Floor Area Valu tion
(commencing with Section 1000)of Division J of the Business and Professions Cute)or
-- Out he is exempt theefrom and the buss for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant.a civil penalty of
not mom than five hundred dolls.(ssao). 3 GWydtEIf)4rO 0 Occupancy Type
❑I,as owner of the properly,or my employees with wages as their sole compensation,
will do the work.and the structure b not intended or.Bared im.ale(See.1044,Business
and Professions Code;Code:The C.ntrxroea Liaise Law does Wt apply m es Owner of Required Inspections
pmpemy who builds Or i.,..there.gand who doetsuch work himulfor through his
own empioyou,provided that such improvements are not intended or offered for asks.If.
however,the building or improvement is sold within one year of completion,Elie owner.
builder will have the burden of proving that M did not build or improve for purpose of
ale.)
.a owner.(ti.property,am exclusively contracting with licensed contractors.
ma the project(Sec.704a,Business and Profusions Code:)The Contractor's Li.
ttu,taw des not apply to an owner of property who Milds or improve thcmon,and
who contracts for such projects with a contractors)licensed pursuant to the Convectors
License law.
❑
NDECLARATION
1 hemby affirm under peulty of perj aro of the following declarations:
1'
have and will maintain a Certificate or Conant to self-Insure far .WorkcrsCompen-
n,u provided for by Section 3100 of d.Labor Code,for the performance of me
for which this permit is isaued.
have and will maintain Wic ker's Compensation luunnce,u required by Section
thc lJbar Code,for the performance of the work for which this permit is issued.
Workers Compensation I..canner and Policy number are:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu well==it not be completed if Ac permit is froom hundred chuars(SIM)
or less.)
I certify thm in the performance.f ds work for which eth[iisB Permit is issued,I shall not
employ any gqeerrpppyj{n) ymannerx o of :J IMworkeri Compensation
Laws o(
N come Subject
the
WO,IL efts{ akm th s noncan:Out
E Labor o d you should
become abjecty it Workeh Co u, visionsof El.IaMr Code,you must
.JO forthwith comply with such Provisions mthis permiuhall be deemed revoked.
Z Vy CONSTRUCTION LENDING AGENCY
(-+ I bemby.lRrm that mere io eouwctinn lending gcncy for me perfumunce of
!Yi
one work for which this permit is issued(Sec.3091,Civ.C.)
Ly] Lender's Name
az Leniari Address
UC 1 certify that I have mad this application and Aare that the above information is
f" correct.l agree to comply wire all city and county ordinsnces and state laws misting in
O V building consvuction,and hereby aumou.rtpresenutiws of Nis city mcnter upon the
W ahovcmenu.nedp.perty foriupeeuon whichpturpros,&
(Wc)agree to save,indemnify and keep harmless the City of Coberdnu against
fa'3 i.c.nocime ce.fin,eostsand.filed .which they in any way accme againstsaid City
U ,`t, A APPLICANT
ofthegranting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
R GULAT ONS.
Z Re-roofs
Sib D te
H RDOUS M ce.p DISCLOSURE Type of Roof
Will tixapplicantor forme buildingoccupant s.mmdlc Heardusm
oaterial
u defined by the Cupertino Municipal Code.Chapter 9.11,andand Health alth and Safety
cw.,sreYea e.nzss3z(a)1 // All roofs shall be inspected prior to any roofing material being installed.
❑ \
/X— If a roof is installed without first obtaining an ins action,I agree to remove
fuw1N'
Will the applicant or m building acupam use csuipmcm or Jcvicu which P
it hazardous air conuminut a u defined by the Bay Area Air Quality Management all new materials for inspection.
WrOO
❑Yu
f have maJ me ha,aNnusmatedels royuiremcnts under Chapter 695 of the Califor-
nia Hc.Ith&Safety Codc.Sceti.ns 155U5.155JJ enEl25535.1 undcrsuM thuif dm huilJing
dose not currently have a vnane mu it u my rnspouildlity m notify tisc occupant n1'the
m cnswh' hmusthmetprior nes eertifie.mof cuPn Signature of Applicant Date
owne Lao mixdagent Z Date All roof coverings to be Class"B"or better