03110072 CITY OF CUI'ER'17N0 ''' "` � "b'• "''
BUILDING DIVISION PERMIT �CONTRACTOlZINF®RMATION.`
BUILDING ADDRESS: STEPHEN JOHNSON CONSTRUCTI NMITNoO3110072
22157 CLEAPCREEK CT
' "NER'S NAME: 155640 KAVIN LN PERMIT ISSUE DATE
MARK & LOUISE LAW 11/14/2003
PITONS' (408) 399-4472 SANITARY NO. CONTROL NO.
ARCHITLCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
I" LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under previsions of chapter 9(commencing Job Description
with Section?DM))of Division 3 of the Buslnesx and Professions Code.and my license is
in fall fomeandarr«t. REMODEL KITCHEN & PODWER ROOM;eeery
; ? Littnx ClearLica
Li B��
,`p Dam Cummctor It t�E
ISD
! ARCHITECPS DECLARATION
C < 1 understand an,plans shall W used as public records
JUL 19`- 2004
aa.t, Licensed Professional
OWNER-BUILDER DECLARATION
<p I hereby onion that I am exempt from the Contractor's License Law far the �IaIYJOrt,r�e
rNb
p o following mason.(Section 7031.5.Business and Professions Code:Any city or county ' R O
<m which requires a permit In construct,alter,improve,demolish,or repair any,animus bbb
prior o its issuance also requires the applicant for such permit to lire a signed statement
< that be is licensed pa.nant to the provisions of the contractors License sew tehaper9 Sq. Ft.Floor Area Valuation
�Fp (commencing wi th Section 7000)of Division 3 of the Business and Professions Crvle)ur
5$ that he is exempt theafrom and the basis for the alleged exemption.Any violation of 32618018 . 00
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of ApN Number Occupancy Type
not roam Nan live hundred colla..(S500). P Y YP
1,as owner of the property,or my employees with wages as lheir.sole compensation,
will do Ne work,and the structure is not intended or offered for sale(See.7 4 .Busineas
and Professions Code:The Contractor's Liceme law does not apply to an owner of Required Inspections
properly who builds or impmvcs Ncmon,and who docs such woh himsclfor through bis
own employees,pmvidcd that such improvements as not intended or offered for Mile.It.
however.the building or improvement is sold within one year or completion.the owner
builder will has the burden of proving that W did not Wild or improve for purpose,of
sale.).
1,as owner of Na property,am exclusively contracting with retained cunb¢tors to
construct the project(Sec.7814.Business and Professions Code:)The Contractor's Li .
me Law encs not apply to an owner or property who Wilds or impro,or Ncmon,and
who contraCtis for such projcc.with a contract orfs)licensee pursuant m the Contractor's
License law. /
❑
I.
can" neer Sec. � n.B h P C for this mazo
!�j / ✓`Date
O KEft',' M ENSATION D ATION
�r 1 hereby alum unJZalty of perjury ter of 0a following declarations:
t]I have and will maintain a Certificate of Consent to self-insure for Worker's Counter-
work
o nt en-
workwork,as provided for by Section 3700 of Ne,labor Code,for Ne peRormance of the
for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the labor Code,far Ne performance or the work for which this permit is iumJ.
My Worker's Cona,mmu lion Insunwe carrier and Policy number art:
Carver: Policy No.: _
CERTIFICATE OF EKEM PTION FROM WORKERS'
COMPENSATION INSURANCE
(This account need not W wmplewd if the permit is for one hundred dollars(5100)
tr Icss.)
I ccnify that in the performance of the work for which this Permit is issued.l shall not
employ any person in any manner so u N WCOMC subject lO the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificate or Exemption.you should
WCome subject to the Worker's Compensation provisions of the Ichor Code,you must
2 forthwith comply with such Provisions or this perm shall W deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
1 hemhy affirm that We is a Construction lending agency Tor the performance,or
> the work fur which this pertnil is issuctl(Scc.1(19?.Civ.C.1
"t] O Under's Namc
Lenders Address
z
U Q I ccnify Nal l have mad this application and site that the above information is
i P correct.I agree to comply with all city and county ordinances and sum laws relating to
.J U building contraction,and hereby authorise apmmntatiss of Nis city to enter upon nor
ahove-mentioned Propony for instruction purposes.
Fr^G (We,)agree to save,indemnify and keep harmless the City or Cupertino against
rq liabilities,judgments,cos.and ea parses which may in any way acerve against raid City /
u in emanownee or the mad.,of this permit. Ill r�
APPLIC UNDERSTANDS N WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR R ULATI
Re-roofs
S' ppBclmVCon am Date
HAZ RE OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding eventual store or handle hvardous material
u de fined by the Cupenino Municipal Code.Chapter 9.12,and the Hearin and Safety
Jc.Section 25532(.)? All roofs shall be inspected prior to an roofing material bei..
❑vas O P P Y g g installed.
Will thea licant or futum buil y preen If a roof is installed without first obtaining an inspection, I agree to-remove
pP ng«cnpaIs esu c til tat Marta which g
ern hrramnus air aonmminan¢ascd by the Bay Arca Air Quality Management all new materials for inspection.
D'xricO � rWY'L/
❑Ycx
1 have mad the hvardous maarials equircmener under Chaptor 6.95 Clore Califon
nia Halo. yCade.Sccuont25N15,25533 and 25534,I understand thaifthe Wilding
docs not c em no
a tenant Na B is m espomibility m nndfy the occupant er the
require n. i mualxm/` no ` once or accrareataOrocc C Signature of Applicant Date
Ow .omen ed seam U Date All roof coverings to be Class"B"or better