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CITY OF CUPERTINO
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BUILDING DIVISION PER
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BUILDING ADDRESS:
NICE & RIGHT CONSTRUCTION
6MITND04030223
OWNER'S NAME:
PERMIT ISSUE DATE
JIM WANG
E:
SANITARY NO. C OL NO.
415
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
i LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licangd under provisions of Chapter 9 (commencing
.41, Seaian TIX10) of Division Sof de, B largA and Professions Once, and my license is
infauY7,40. cnea �,` •/' Q���'F58
ADD 668 SQ.FT. (BEDRM/BATHRM)
Liccn#.Class
Corsa
•Contr
EC ION
ARCHITECTS DEt�T10N�—
r IProfsla.J my plans shall WuxJupublic records
4
4 _
Licensed Pmfessinnel
OWNER -BUILDER DECLARATION
I W.so affirm Nat 11. cumpt tram lW Cssions Anyca. Law for the
a :
followingrcuoa Permian T(Inl.&e. altmssand Cade: Any CLOY. county
improve, demolish.
which requires a permit M cortsuucl. stmt, improve, demolish, nr minor any xtructurt
�
prior to its issuance. also mquima the applicant for such permit to File a signed natomcm
Convector's License UW (Chapter 9
Sq. Ft. Floor Area
Va uau n
that he is licensed pursuant to the provisions of the
(commencing with Section )000) of Division 3 of the Business and Prormsions Code) or
that W u exempt domfr m and the basis far the alleged totmin nt. My violation of
31AdTRQI&R)er0 0
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant m a civil penalty Of
not more Nan Ave hundred dollars
1, as Owner of the property, or my employeas with wages as Back xle compensation,
Required Ins
e eetlOn$e
q
will da the work. and One structure is not intended oroff,.d far rale(See .]Daa. Business
and Professions Code: The Contractor's Licemlaw does not apply to an owner of
P
property who bu ildx or improves thereon, and who does such work himself or Ihmugh his
own employes, provided Nat such improvements art r atintandcd or offeree for sale. If.
however, the Wilding or improvement is sold within ane year of completion, the owner -
builder will have tW Wrden of proving that he did not Wild or impown for purpose of
mlc.).
❑ has owner of the property, am exclusively contracting with licensed cmudectory to
construct the project (Sec. 7044. Business and Professions Cade:) The Contractor's Li-
cense law does not apply to an owner of property who Wilds Or improves thereon, and
who mnuacts for such pmjeca with a contractor(s) licanxd pursuant to the Contrsemr's
License Taw.
.
U 1 an exempt under Sec. . B Ar P C for this main
OwnerDau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury mac of the following declarations:
have and will maintain a Cerurinu of Cement m self -insure far Worker'sCamper-
mtion, as provided far by Section 3700 of the Latin, Code, for the perfmmana of the
.,it for which Nis permit is issued.
❑ 1 have and will maintain Workcfs Compensation Insurance, as required by Section
37OB of Ne Labor Cade, for the performance of that work for which this permit is issued.
My Workers Com creation Insunna eamicr and Poli, number art:
C- - Poli, I
, �r.j CERTIFIC OF P ION FRO WORKERS'
COMPENSATION INSURANCE
mos xctirm need not W completed iRW permit is form. hundred dollars (3100)
or less.)
I certify Nat in %e perfa....Of the wart for which this permit is issued, l shall and
employ any person in any manner x as to became subject to the Workeff Compensation
Laws of California. Da.
Applicant
NOTICE TO APPLICANT: If, after making this CCdHimu of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cam, you mot
forthwith comply with such provisions or this Permit shall W deemed revoked.
,
CONSTRUCTION LENDING AGENCY
UCTION LENDING AGENCYthea
is a Construction mnding,gm y' for the perfarnance or
f wart for which this permit is issued (Sec. 3097, Civ. C.)
Isnecr's Namc'
Lcndeis Add.
I certify that 1 have read this application and sou that the above information is
Carta 1 agree to comply with all city and county ordinances and sou laws relating to
building construction, and hereby authonm mprexnmivme of this city to cntar upon the
above-mmuaned property tot inspcnion porpaxa
(We),gme to save, indemnify and keep handless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against mid City
in conxqucnce of Bac greeting of this permit.
d
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIM'
Issued by: Date
SOU GULATIO Is
Re -roofs
SApplicamlCoidurruclor Data
HAZARD ATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building Occupant store or handle hamrdous material
as de0ned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
t
Code. section 25372(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑YCs No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fuwrt building occupant sex equipment or devices which
harafdous air contaminants as defined by tW Bay Area Air Quality Management
all new materials for inspection.
Yes
I have.xJ the havardous maurials teyu near.a s under Chapter 6.95 of the Califor-
nuHCalth&SafSty Cock,Savam25505,25533and2553a.lun&crs wifthc Wilding
docs not currently have a tenant Onto it is my responsibility to notify the occupant of the
mquian.nL which must be nor to imaat f' ccrdficatharaa an,.
moscnl
Signature of Applicant Dale
7 __ a
All roof coverings to be Class "B" or better
0 ore Dam