06010014 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ': !@+ONTRA:G'CUR,TNTgRMA`)CI N:;':
1BUILDING ADDRESS: PERMIT NO,0 6 010 014
21708 ALCAZAR AVE
OWNER'S NAME: FEtMITLffiUEDATE
YUN KEI TSANG Q-7/03 /2P-Q,C
NE: SANITARY NO. CONTROLNO
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hcmby affirm that l am limited under provisions of Cltaptar 9(commencing Job Description
with Sction 7")of Division 3 of the Business and Normans Cade,and my license is
(8� ADD 452 ' -KICHEN/BATH/LIVING/BEDRROOM
In full forte. effort.
� p Deto Clase -pOLIVI- GARAGE 433 ' /REMODEL 885 '
❑W❑W ARCHPfEC rS DECLARATION
u
f�0
I undennd my plans dull W used as public records
s Licensed Peleasmnal
`e5 OWNER-BUILDER DECLARATION
c._ I bushy aMm that I am exempt from the Contractors License Law far to
coo following moon.(section 7031.5.Busmen and rve.da oll Code:Any city m county
5$ which requires a permit re cores tho applicant improve,demolW,ore&Al ed tweet, �1 shta,
-Zi priorW its kensedP tlo ngmmNovisiosOfthosashpemr"LicnseLaw(Chap=n' Va$Rb@470
E G thatWWlicensedpurwemaoaWpoviaiono fticConuacuttlJccnxelaw(CMpler9 Sq. Ft. Floor Area
I (commencing with Section 7000)of Division 3 of die Bottom and Professions Code)or
Q`<g that ho is exempt themftom and the basis for the alleged etvnpdon.Any violator of
Suction 7031.5 by any applicant for a permit ob"the applicant to a civil penalty of r4v,},f9vr�lmber Occupancy Type
not mart than five hundred dollar(3500). 3 M! U 14 . 0 0
0 Luowncrofthe property,army wployceswiN wagesu teirseecomperwtan,
will do theworkma themuaum isno tl mmndedorolrecdfauak(Sm.7W.B".s Required Inspections
and Professions,Code:The Contractors Lleense law tan ant apply W an owner of q P
property who builds or impmvn Wercon,and whodonauch work himau forthrough his
own employ=,provided thataueh Improvements;are oat intended aroRecd for Ole.If.
however,the Wilding ar imp owmmt Is old within am you ofcompletion.the owner.
builder will have the Widen of proving that he did ant build or improve for purpose of
Ole.).
V/1.as seer of Nth pmpcny am eolumvely m unicting whe limned comwtms in
construct the pmjecl(Sec.7014,Business W Profemoas Cade:)The Canmeura u.
cane law does rat apply in an seer of prupe ,who Wilds,or improve thecon,and,
who contracts far sash pmjero with a contractors)licensed pursuant to the Conusctets
Louise,law.
Ctorn asempt under See .B St P C fm this won
,Owner ---�� �Y/ Data
WORKERS COMPENSATION DECLARATION
I Macey aRlm under penalty of perjury am of the following declaration:
0 than and will maintain sCenifiata of Consent to self-lasum for Worker's Compen-
sation,as provided for by Secton 3700 of the labor Code,fm the perfamance of the
work for which this permit is issued.
0 1 haw and will maintain Workers Compenaton Insurance,as taloned by Section
3700 of the labor Code.for the perfommee of the work for which this permit is Issued.
My Workers Compensation Insurance carrier and Policy number w:
Carrier. Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This tcmlon teed ant W cempleWtl If to peen Is fmonehunaml0ollan(5100)
or lava)
1«mfy then in use partition.of We work fm which Nis permit is laced.)shell not
c:nployany person In my man r aheart to Nth Wanduaf Compmadan
Laws of Calif.ord.Data al
heart
i w
NOTICE TO APPLICANT:IL a eking this C er ifiam of Exemption.You should
bnome subject W Its Workers Compensation provision of Me labor Code you most
�Q forthwith comply with sash pransian or NU permit shall W accused revoked.
ti CONSMUC71ON LENDING AGENCY
[-t 1 WMby,affirm also Nee it a coasaoNnn lending agency for the performance of
rl the work fur which this perch m Issued(Ss,.3097,Ch,C.)
W Q Lender's Name '04 z lenders Add,^
U 0 1 certify that 1 ban,read this application and sum that the show information is
it, correct.l agca to comply with all city and county ordinances and sum laws Misting to
0 building convection,and hereby anhorim reinicnatsuvn of this city to enter upon the
>"W above-rawm aned property for inspection purposes
M (We)ague to On,indemnify and keep hamlets de City of Cup Mina.geimt
rFa h IiabilideAjudgmoms,costs and expenn which may in my my amoe againa mid City
U z m c-magmana of Nc ranai t of Nis permit /
APPLICAM UNDE N OS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date / ?1
SOURCE RE GUJLA
fn� Re-roofs
Sigaaurcof Apif TypeafR oof DMATERIALSDISCLOSURE
Wall Nth appllont or f riuc Wilding aucupantamro of handle h.sardaas maim i
u defined by the CupeNna Municipal Cade Crispier 9.13.and do Health and Safety
Code.Sued..15533(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yn PNo
Will the applicant or future Wilding occupant use equipment of&vim which If a roof is installed without firs[obtaining an inspection,l agree to remove
emh huardem,air consoninants as defied by Nth Bay Area All Quality Management all new materials for inspection.
Dimict7
OYaa 01N.
I haw mho the hanNaas mawfialsrequicmenu underCTapor6.97 of the Caliper.
HCgI
-'an" .Seed.m35505,35533aa135534.1undentsnd NWlflhe building nJn ant Nc&mnty h a
ant.Nat it u my mpooibiliny w.wly the=upset nl Nth
myuicmcnW which join ntet pnorW tssumm era Ccmficam of OCCa e. Signature of Applicant Date
All roof coverings to be Class i'B"or better
Owner or Obq etl age I C /
Data.
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