03080125CITY OF CUPERTINO
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INFOR�VIATION
BUILDING DIVISION PERMITCONTRACTOR
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BUILDING ADDRESS:
BASIC CONTRUCTION SERVICES
PERMIT NO.
03080125
A
PERMIT ISSUE DATE
15197 DICKENS AVE
NE:
(408)369-0257
SANITARY OL NO.
ARCHITEC IENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
lob Description
19ewby eMon that I am licensed under provisions of Chapter 9 (commencing
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with Seel n f Division J of the BaN�nra�v Profcui m code, and my license..+
it Tatem d. l" 1.3t� 3\-7
Lkense
REMODEL KITCHEN/2 BATHS �eJ
°am
TERMITE REPAIR
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OF 3 WIN O
ARCHTIECTS'Qs ATION
public
I ndcratand my plain shall he used as public records
JAN lo- 20051
Licensed Pmfcssinnal
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 em exempt from the Contractors Uccnse Law for the
fallowing rtuon. (Scctiun 703 1.5, Business and Profcuines Code: Any city or County
which requires a permit to convect, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant far such permit to fila .signed summer,
Contractor's License Low 9
Sq. Ft. Floor Area am mor I MW000
that he is licensed pursuant o the previsions of the (Chapter
(eammencing with Section 7000) of Division 3 of the Businev and Profusions Carle) or
that he is exempt therefrom and the besis for the alleged esemption. Any violation of
3 MY2' qu2I!er0 O Occupancy Type
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom man five hundred dollars (9500).
❑ 1, as owner of the property, or my amplayets with wagew than SOIC compensation,
Required Inspections
ee: q P
will do the work and the structure is no, intended or offered far aah(See. 7044. Business
and Professions CodThe Contractor's License Law does rout apply ed an owner of
property who builds or Improves therrnn, and who does such work himself or through his
101
- FOUNDATION
own employees, provided that such improvements trona, intended or offered for ale. if,
lO2
PIERS
however, the building or improvement is sold within oro you of completion. Jin owner -
—
builder will have the burden of proving the, he did not Wild or improve for purpose of
103
- UFER
sale.).
104
- REBAR
❑ h as owner of the property, am exclusively contracting with licensed commune to
comtmctthee prejectSec. 704",Business and Professions Code:) The Conuumr'sLt.
105
- ANCHOR BOLTS
came law does not pply to an owner of property who builds or improves menton. and,
lO6
SEWER WATER
who contracts for such projects lrsm with a eonctort) licensed pursuant the Contractor's
— &
License Law.
202
- UNDERFLOOR PLUMBING
❑ I am exempt under See. . B k P C for Leu rtuon
203
- UNDERFLOOR MECHANICAL
r Dow
204
- UNDERFLOOR FRAME
WORKER'S COMPENSATIONDARATTION
ECL
r Ihereby aiederpemhyafperjaryamofthefonow...&declaraiam:
rm.se
205
— UNDERFLOOR INSULATION
I haw and will maintains CeeifimmofConsenHo self -insure for Worker's Compere
301
— ROUGH PLUMBING
anon, es provided fat by S"dan 3700.f Je labor Cade. far the perfamrace of the
302
- TUB & OR SHOWER
work for which this Permit is issued.
❑ I haw and will maintain Worker.. Compensation Insurance, as required by Section
303
— ROUGH MECHANICAL
77M of the labor Codc. for me performance of me work for which this permit is..teuW.
304
— ROUGH ELECTRICAL
My Wo ce.c.. enanonlmunnmonkranaa Policynumkram:
305
— FRAME
'er�RION No.: 0000
`CERTIFICATE OF (EMPr10N FROM WORKERS'
306
— HOEDOWNS
COMPEN ATION INSURANCE
307
- INSULATION
(Thissec0on need no, be completed If be Permit s for one hundred dollara(s 1010
308
- SHEETROCK
nr ksq
1 certify mat in the performance of the work for which this Permit is items. I shall not
309
- EXTERIOR LATH
employ any person in any manner a as in Hceome subject o the Worker..Coatpe.sNan
310
— INTERIOR LATH
Laws of California. Dam
311
313
- SCRATCH COAT
- ROOF NAIL
Appilcant
NOTICE TO APPLICANT: IL after making this Cenifiate of Exemption, you about)
become subject m the Worker'a Compensation provisions of the labor Code, you most
faMwith comply with such provisions or his Permit shall located worked.
501
— FINAL ELECTRICAL ENERGY
CONSTRUCTION LENDING AGENCY
502
- FINAL PLUMBING ENERGY
I hereby affirm mat there is a construction lending agency far the performantt of
503
- FINAL MECHANICAL ENERGY
the work far which this permit is issued (Sec. 309'1. Civ. Cd
Lender's Nunn
504
505
- FINAL BUILDING ENERGY
- FINAL' ELECTRICAL
Lenders Addwa
I ttnee that I Mw read oris city and coup y o sum mu me above information rmaiun u
correct. l agree to comply with all city end county ordinances and sate lows relating to
506
GAS TEST
building construction, and hereby authorise rtpresenutim.f. this city to enter upon Jin
FIN PLUMBG
abovwmentiuned property for inspection purposes.
(Wc) agree to ave. indemnify and keep harmless the City of Cupertino against
0 8
F I L
Ilabilitles,judgmenu, cosu end expenus which may in any way accrue against aid City
in eon+equenec of Jou granting of this perm..,.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: 5
Date
SOU GULATION
Re -roofs 514
Type of Roof
NAL PUBLIC WORKS
-
iL. yrC — - 9na •2S,o:
Si aturtol'pplicaVCommecar Dam
HAZARDOUS ARIALS DISCLOSURE
Will be applicant or future building occupant stow or handle havardaes arsenaldemmd
by the Cupertino Municipal Code, Chapter 9.11. and the Health and Safety
Section 25532(.)?
❑YesPo
All roofs shall be inspected prior to any roofing material being installed.
future building devices
If a roof is installed
without first obtaining an inspection, I agree to remove
Will me applicant or occupant ase equipment or which
Tit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Istria?
❑ Yes
I have mad no Mandous mamrials regwwmenu under Chapter 6.95 of me Cali
at,
ria Hmldr At SafclyCnde. Sectiam 25505,15533 and 25534.1 understand Less if he building
boa no,, urrently haw a mnam, that it it My rtspamihility m nobly the occupant aJe
ustbemetpsormiteaanucofeCeNOcamo(Occu
SignatureofApplicant Date .
3
All roof coverings to be Class "B" or better
wnerm.ntnorianJ Caen, Data