04100085 CITY OF CUPERTINO
nuu.Dwc Drv1s1oN PIJRMIT " CONTRACTTOR41NFORMATION��
OUILONG ADDRESS: - PERMIT Nd.4 l O O O B S
0314 ANN ARBOR AV
Ow NER'S NAME. PERMIT ESUE DATE
al YAO SUN 10/13/2004
IN F HONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
so, LICENSED CONTRACTOR'S DECLARATION C7 O O O
i u C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Descrl
> =
With Section rpoianJarn i`ai 77�3n.coe..namyueen is ELECT SERVICE UPGRADE (20L�� ��u®
in4n Data cantmno CONTRACTOR: WEST VALLEY EL
n j ARCHITECTS ^
5i W U 1 undccstanJ my plans shall W uscJ a uhlit rcttnJs 04y 2004
soo 1
3 u0 N Licensed Professional L 4
S OWNER-BUILDER DECLARATION I
.�0 0 I hereby.(Sens that 1 1, exempt from the Contractor's C License Law for the
S oe O following rcaon.(Section 7117 L5.Business and Profeainm Code:Any city or county
><m which requires a permit us Construct.alter,improve,demolish.or repair any structure
Fiy prior or its issuance.also regshres the applicant for such Permit rile a signed statement
EmC
that he islicensed pursuanuotheprevisionsoftheComenclor'sLicenseLaw(Chapter9 Sq. Ft. Floor Area Valu 7
9t— (commencing with St Ma7W0)ofDivision3ofine Briamessand Professions Cmle)ser
a.`s Nat he is exempt therefrom and me basis for one alleged exemption.Any violation of
Section 7(131.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not mom thanean five hundred dollars(SSW). 32655020 . 00 p y Type
❑ 1.as owner of the property,or my employees wish wages as their sole compensation,
will do Use work.and she strunum is not intended or offered for sale(Sec.)IkJ.Business
and Professions Cable:The Contractor's License Use does not apply to an owner of Required Inspections
property who builds or improves hromm,and who doessuch work himself arthreugh his
Own employees,provided mm such improvements are not intended at offered for sale.If,
however.the building or improvement is sold within one year of completion.she owner- '
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale)
(—j 1,as owner of On property,am exclusively contracting wish licensed contractors to
continues the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
came law does not apply to in owner of property who Wilds or improves themon,and.
who commets for such projects wish a cartoonists)licensed pursuant o the Contractor's
License Law.
❑1 am exempt under Sec. B sk P C far this mason
Owner Date
WORKER'S COMPENSATION DECIARATION
41 1 hereby.(finis under penalty of perjury one O(the following declarations:
I ham and will maintain a Certificate of Camscnt to wlf-imum for WorkelsCumpcn-
sation,as provided for by Section 37W of the labor Code,for the perfoommo,of Nc
work(os which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Imunncc,M required by Section
37W of the labor Code,for em performance of the work for which this permit is issued.
My Worl is C�mpen/slation Insurance carrierd Policy number art:
ante Com, Ida S-Ir Policy o:7I9C%>/
CERTIFIC OF l EMM OM WORKERS'
COMPENSATION INSURANCE
(This section need nut hecompleted if the permit is farm.hundred dollars(SI W)
or Inti)
1 certify thm in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner an as m hecome subjecua the Wofkeri Compensation
Lawsof Califom;a.Data
Applicant
NOTICE TO APPLICANT:IL alter making this Ctnificam Of Exemption,you should
become subject to the worker's Cosupewtian.pmvisions of the Labor Code,you must
Qz fonnwith comply with such previaions or this permit shall he deemed revoked.
zCONSTRUCTION LENDING AGENCY
F' I hereby affirm Nat them is a construction lending agency or the performance of
(Y she work for which this permit is issued(Sec.3W7.Civ.C.)
y0 LenderName
a z lender's Add.
I
J Q sonify Nal I have read this application and sum that the above information missing
is
,y U bonding I agree to comply with all uth and county undoes Of and state laws relating he
Q V abovbuilde mentioned construction,and herebyiautnori'm.prescnulitcs of this City to toter upon Nc
,ma. ahovc(We;agree to snyfor;mnify an keephs.
gy (We)agree m cast,indemnify and keep harmless the yCity of against Mid
y inconsegjudgmentseroslsand expenses which may in any way accrue againstsaid City
Oz A APPLICANT
of DERSTgranting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ����yyylly��ATIONS.
�
' Re-roofs /
fico ApplmanVComracmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant ser future building accudar�tpre m handle haoNuus mensual
m defined by the Cupenom Municipal Cods.Chaps 9.12,and Use Health and Safety
Cole.SO Yes 25532(.)? �a ._. All roofs shall be inspected prior to any roofing material being installed.
Will mea applicant or future building Occupant use e If a roof is installed without first obtaining an inspection, I agree to remove
PP g 0 a Air Qu or devices which g P
reit Emardnus air contaminants as defined by Lite Bay Arca Air Quality Management all new materials for inspection.
Dimricl? /
C]Yes 16 No
I have read the ha,aNnus materials requirements under Chapter 6,95 of the Cal irm.
nix liealds do Safety Cote.Seeuum 255)5.25533 and 25534.1 uaskrsmnd 0.if the Wading
dors not currently have a tenant.mat it is my msponsibil ity upa
s nnuly the occupant Of Ne -
tswh Most
IN,mdtpoor seis.xnwors eeturrmofOrewamer. Signature of Applicant Dale
aatwrize gent ,tp All roof coverings to be Class "B"or better $