11050058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1 1002 NORTHSEAL SQ
CONTRACTOR ""D PERMIT NO: 11050058
OWNER'S NAME: BOHRINGER WILLIAM F AND PAULIN
i DATE ISSUED:05/10/2011
OWNER'S PHONE: 4082445922
' PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG � ELECT � PLUMB �
License Class -�-y Lic.#
ContractoC2(_/ ' /fit/ t� pMECH RESIDENTIAL COMMERCIAL
E:7Date_
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMODEL EXISTING KITCHEN(90SQFT).FLOOR PLAN WIL
(commencing with Section 7000)of Division 3 of the Business&Professions REMAIN EXACTLY AS IS,ADD NEW RECEPTICLES(3)NEW
Code and that my license is in full force and effect. LIGHTING(REPLACE 4 EXISTING WITH 4 LED LIGHTS(UL
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker'
Compensation,as provided for by Section 3700 of the Labor Code,for th
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued. Valuation:$11340
APPLICANT CERTIFICATION APN Number:31640038.00
I certify that I have read this application and state that the above information is Occupancy Type:
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FRO T CALLED INSPECTION.
9.18.
Signature S� 1l Issued Date:
Date /
OWNER-BUILDER DECLARATION
—,!by affirm that 1 am exempt from the Contractor's License Law for one of RE-ROOFS:
th-e following two reasons: All roots shall be inspected prior to any roofing material beteg installed.If a roof is
I,as owner of the roe installed without first obtaining an inspection,I agree to remove all new materials for
property,rty,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant:
I,as owner of theroe Date:
p p rty,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,1 Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must O er ora thorizedagent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date: /?>
i
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of Hork's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
grant;-of this permit.Additionally,the applicant understands and will comply
wv on-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional