05070096 Permit CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,_C0NTRAtT0R:INF0RMATI0N:,z
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BUILDING ADDRESS: PERMIT NO05070096
Q054 ADRTANA AV
'HR'S NAME: PERMIT LSSUE DATE
HENRY HUANG _ - Q9/23/2005
PHONE: SANITARY NO CONTROL NO.
ARCHITECUENGINEER, BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED a CONnsed under previsions UEC of Chapter w 1 hereby affirm Net I am licensed under and!Fi of Chapter i(commencing lob Description
�iin with Station ad( fof Divison]of NC Business aid Prafcssiom Code.and mylittmea
n<oa°i mmummeanaeccct 1119 ' ADD 2 BEDRMS/1 BATH/KITCHEN/FAMILYRM
j z License Class Lic.N
gr00 Dam Contractor NOOK/ENTRY/294 'GARAGE-REMODEL UTILITY RM/
ARCHITECTS DECLARATION 2 BATHRMS . (250 ' )
¢ 1 understand my plans shall he used as public retards
JaU
s o Liceriscd Professional
3 OWNER-BUILDER DECLARATION
<q 1 hereby affirm that I am exempt from the Contractor's License Law for the
p me
arm following man (Section 7131.5.Business and Professions Code'Any city or county
�,°a which mquircs a Pmmu m construct,alter.improve,demolish,or repair any structure
¢r prior in its issuance,oho metres the applicant for such Permit o file a signed atammem
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that he Sq. FL Floor Area Valuation
yrcF$ (commencing with Section 7")of Division 3 of the Business and Pafcamia Cade)Or $281643
Nat he h exmmpt therefrom and the bash far the allcgcd exemption.Any violation of
Section"l 031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom than five bandied dollars(S500). P Y YP
❑Lazow arse.the pmpcnyar myemplaym wnhwagesazthe(Sec.compensation, 1��,�,rr
and Pr the work.and Ne he Con h noun Lice of offered w does n t apply to an Owner
and entywh bit Calc:The Contrector's License Law does not apply to an owner is Required Inspections
property who builds orinfinities el Oat chereprove who doeasuchwork humselfor
edthsaugli his
Own cmployeuiprovided Oat such rat is smments artmyear ftoraction,tic,o owner.builder.Ne buildinguimprovements Oat year of mproefor NC awn u- ,ttr�gt--t ®®® f��- rte,
builder will have lm burden of proving chat he did not build or improve for purpose of � ��
tale.).
4!�1,as owner of the property,am exclusively contracting with licensed contactors to
construct the project(Sa,.]DW,Business and Professions Cadc)The Contractor's Li-
came Law does not apply in in owner of property who beads or improves thereon,and �
h canmrcts for such pmeca with a contractor(s)licensed pursuant m the Canuactors " '1Fg-1'1/gpg'-s'`II `{*�ergJ......I
, aempto 6RKER'S¢O NSA ON DECLARATIONPC mfJ�46�f./�aa V
1 hereby affirm under Penalty of perjury arc of the following declarations:
❑Ihaw and will mantaina CcniFinmorcowntioslf-insumrorWorkerscompen-
samn,se provided for by Section 37W of the labor Code.for the Performance of Pre
work for which this permit e,issued.
❑1 have and will maintain Worker's Compensation iinunntt,as"uimd by section
3700 o(Ne Labor Coe,for the performance of Pre work for which me Permit s issued
My Worker's Compensation Insurance carrier and Polity number am:
Cartier. Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need rim bec..,Icmd Bile permit is fnrwc hundred dollars(5100)
or lase.)
1 certify Nat in die Ferfarmar¢e 00 work to wh 0 Nis Permit is issued.l shall not
employ any posomm say man, cc jc to the Workcri m s dpi
Laws of California.Dam S
Applicant
NOTICE TO APPLICANT.If.after making dus Certificate of Eemption.you should
become subject m the Worker's Compensation previsions of me Labor Code,you must
z forthwith comply with such provisions or Nis Permit shall he dremed mvnked.
z CONSTRUCTION LENDING AGENCY
I Trolly Affirm Nat them is a construction lending agc
ncY for the Performance of
a Le work for wh¢b Ms perms is issued($CC.NN,,Civ C.)
IA Q lender's Nam-
IL
a,,Z lender's Addrts
U 0 1 certify Nn 1 have read this application and sate Nat the above efom alma is
V. F^' correct 1 agfce to comply with all city and county ordinances and state laws rtlaung to
budding construction.and hereby autborre mpresenauvu argues city m enter upon the ^
a shove-mentioned pmp riy(in inspection purposes //
(We)silica to eve,indemnify and keep harmless the City of Cupertino against
f^N IirOdud.,jud,mcnts.coats ands.,.which may in any way ac c.against said Gty
V z in consequence of the gram""'of t m perms.
^' APPLICANT UNDERSTAND NO WILT.COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. /� . � ..
Re-roofs
Signature of ApplicamyCOn Dam
HAZARDOUS S MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future W Jdmg occupant atom or handle heaamous malarial ,
#
defined by Ne Cupemno Municipal Code.ChaPmr 9.12.and the Health and Safety
.OYC'n 25532(a)v ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmn hvardous air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
DOOTO
❑Yes [2 No
1 hive mail the baaamims materials requirements under Chapter 6.95 of the Cab fro-
is Health&Sammy Code.sectiom 25505,25533 and 15534.[Innervated 0.ifde Wilding
Jam not currently tenant Ned u my rtspmmihNy io nnoly the acuPant of the
requiremmawhm m,Imirnip aslaiicear,ctmfateor` ty Signature of Applicant Date
F __9 All roof coverings to be Class"B"or better
Owner or authonAd agent I i Dam g