03060127.00FR�
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CITY OF CUPERTINO
BUILDING DIVISION PERNIIT
�O' NItACTORINFOX2.MI.TIQIV...
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BUILDING ADDRESS:
ELIZABETH LEE
PERMIT NO 03060127
OWNER'S NAME:
SIT M V pA71 8/ 2 O O 3
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB
MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 bertby affbnl Out 1 am licensed under provisions of Chapter 9 (cmoun cis{
with Section 70110) ofD"'Imm S of the Business and Pmfeeriov Code. mal my license I-
I. and.Tang L leense Chat JC. N
KITCHEN /2 BATHRMS UPGRADE &
TERMITE REPAIR
Dam Contractor
ARCHMCrS DECLARATION
I understand my plans NalI W used as public mama
Licensed Prefess+onel
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from We Contractors License law for IN
following moon. (Section 7031.5. Business and Proreuions Cade: Any city or county
which mquirea. Permit ro construct, after. harrow, am Wien, or repair my wuelum
prim to is issuance. also requires the applicant for such permit to file a signed ualcanchnt
F
Area
Valuation
that he is licensed pumanl in BM vi met dlC ConlOebr wfQhetw..,
(
OOr
b: momming with Section]0n0) eB Pra`fe 'otb Cade)m
�l
`I 1
li
$25000
that he Is esempl therefrom and t ic as"! My v1oWUm of
Section703l3byanYapplicant(t perm Itsubjea9deappT4mnelo pviipcmm try Or,.
not mom than Bw hundre d aIWS W). �'M1f lY.
! �t�i PN
�l
umber
Occupancy Type
i
�mdplay
Ij _3 6
i� t
024.00
❑ Luowrcrofthapmpmy, arm with w{uuthetrm1. cmpewdan,
101
- app °yQt�[�d Inspections
- FOUNDA 1 1 VN p
wBldothewortandtneawatweb' t+nundedortiff ro rule -ISec. ]06d.e sm"
and Profession. Cade The Con a Liatue yLgww ddWoes oo��p ly to an avineeN
property who Wilamimprovu _-sddw �ycasah�w2rkfi)msdf or Uuough his
awnemployeu,pmvidW thmauchi rowmenu are rctlnmMW mofferee fmsale.Ir,
102
— PIERS
nownwr, the building or impmwmenl is mid within arc year of completion. the owner -
builder will haw We burden of proving that be did not build w improve for purpose of
103
- UFER
aaa.
104
- REBAR
❑ I, as owner of the property, am exclusively announcing with licensed commons to
105
- ANCHOR BOLTS
construct the project (Sec. 70M, Business and Profession Code:) The Contractors W-
censeLaw does a., apply an anowearOf property, who Wilds arimp ..temon . and ,
106
— SEWER & WATER
who contracts for such projecu with .boom¢Ipr(s)11¢nsed purswntto the Conuacmrt
202
- UNDERFLOOR PLUMBING
Cf
❑lam ezt ypOg See .BA PCfo th4 mason
203
- UNDERFLOOR MECHANICAL
rgtpt
r J�1// -/f .
204
- UNDERFLOOR FRAME
a
DECLA N
Ww
205
- UNDERFLOOR INSULATION
1 hereby ellhm under peu11Y of perjury arc of de following aclantlonc
under$COMPENnjurya
301
— ROUGH PLUMBING
'
(hawendw+llmainu)naCenineamof Conunuoulf- Imumfmwmkers Compcn-
,Wan. as provided for by iml nor ofthe Iabm Caa. fmdu Md.. of the
302
— TUB & OR SHOWER
work lot which this permit isiuwd.
303
- ROUGH MECHANICAL
❑ 1 Mve and will maintain Worketa Compensation Insunnoe, u required by Section
304
— ROUGH ELECTRICAL
37M of the Labor Goa, for as performance of the work for which this permits issued.
My Workers Compemdon lnstuauce nrticr and Policy number are:
3055
— FRAME
cards _Policy No.:
306
- HOLDOWNS
CERTIFICATE COMPENSATION INSURANCE ORKERS'
307
— INSULATION
ClImsmdon need cn becomplcud ifha permit is forom hundred Oil= ($10(r)
308
- SHEETROCK ,
.it=)
309
- EXTERIOR LATH
I certify Wet in the perfnrmanc of We work for which this permit is Issued, l shall nor
310
- INTERIOR LATH
employ any pe mmrcrmas the Warkdn'Cmnpensedon
Vmeybjectm
Lawson C.l+ram a. .55 ,,YP��G
311
313
- SCRATCH COAT
- ROOF NAIL
A"Ecan )F.1Z
NOnC APPL7CANT. If. aMrmak+ ngthisCertlftnuof&cmption.youWauW
become, m the Workers Compensation provisions of six labor Codc, you am
501
— FINAL ELECTRICAL ENERGY
forOwi comply with such provisions or this permit sball be deemed revoked.
502
- FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
I Wmby affirm that them is.amwcOm lending.ji nor de perfornew. or
503
- FINAL MECHANICAL ENERGY
the work for which this permit ls issued (See.3M.CIv.C.)
504
- FINAL BUILDING ENERGY
t.enars N.me
505
- FINAL ELECTRICAL
Lcmin's Address
I entry wt 1 low and sum than the sbeve m H
dtisty
506
— GAS TEST
anVation
comply with all city and county amdinan and runs law misting m
bonding I agree with
'
of r upon
building eonsweuon, andnereby wthMse rtpmaenutiwa of this cloy to enta upon rite
c
— FINAL PLUMBING
above- mentioned properly for inspection purposes.
O
F I L
(Wed .gm e to a". indemnify and keep harmless the City of Cupertino agdml
�.v
liabilities. judgments. costs and upenses which may in my soy accrue against said City
I
in cmmeroame of the granting of this permit.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by 5
SWN�C Date
SOURCE R A,710NS.
(
(t � — 61116:5
Re -roofs
Type of Roof
nuuuof pliwnJConualar ate
HAZARDOUS MATERIALS DIS OSURE
WILT theappliesm wfuture building aecu. time mhem'k hnallom material
u dented by the Cupenim Municipal Cade. Chapter 9.13, and the Health and Safety
ode. Section 25532(a)?
❑Yin Yj No
All roofs shall be inspected
prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
9411 the appltcmt or fumm building Occupem use equipment or avid which
Is mous air conumtnanu u denacd by the Bay Area Air Quality Management
all new materials for inspection.
uric@
In ave mad the hmaNau matoriale rtquimmenu u n der Chapter 6.95 a (the Cal ifoo-
nuHes+thgeSaimyCado Swtircs25505.25533uW2553c.)una Rifled building
us
does sal currently hew a Wheat, that it u my mini ily to notify the eccupanl of the
mcydrtmeu mtwbemet 'rmlrrmm i Cra
Signature of Applicant Date
'(77113
All roof coverings to be Class "B" or better
'
owner ai odacd agent W