03110034 CITY OF CUPERTINO ,� ^' ^"i+'11W Vska";�<a 'r
BUILDING DIVISION PERMITCONTRACT,OR,I(NFOR, MATIO N ;
BUILDINGADDRESS: NEIL CHANG PERMIT N003110034
, NER'S NAME: PERMITLSSUEDATE
NEIL CHANG 11/07/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30o LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Seclion 70(Xj or Division 3 of the Business and Professions Code,and my license is
+ � infull form a.d.fre01' REVISION--IN HOUSE USE ONLY
12� License ClassLic,M
Dam Contractor NO NEW PERMIT/ORIG. #03110034
WARCHITECTS DECLARATION
I understand my plans shall M used as public records
U
Liumtsod Professiontl
OWNER-BUILDER DECLARATION
S! I hereby affirm that I am exempt from the Contractors License Low for the
00 fallowing moon.(Sceuun 7131.5,Business and Professions Code:Any city or county
53� which requires a Permit to ennslroci,almr,improve,demolish,or repair any structure
_aI poor o in issuance,also requires the applicant for such Permit to rile a signed statement
0aE 9 that he is limmod pursuant to the provisions of the Contractor's Umme Law(Chapter 9 Sq. Ft. Floor Area Valuation $0'
e Q (commencing with Section 7")of Division 3 of the Business and Profession&Cole)ser
that he 13 exempt therefrom and the basis for the alleged exemption.Any viniation of
Section 7031.5 by am applicant for a permit subjects me applicant to a civil Penally of 3 APISTIf>khla ller 0 0 Occupancy Type
not more than rive hundred dollars(5500).
❑I,u owner ofthe property,or my employees with wages w their sale compensation,
will do the work,and me structure is not intended or offend for sale(Sm.70ol Business Required Inspections
and Professions Code:The Contractors License Law does not apply m e an owner of q p
properly who builds or sorrows Nereon.and who doessuch work himselfar through his
Own employees,provided that such improvements so,notimunded oraffercd far salt.If.
however.the building or improvement is sold within one you ofcompletion,me owner.
builder will have the burden of proving Net be did not Wild or improve for puryom of
sal.j. \
\
El 1.as owner of the property,am exclusively contracting with licensed contractors to S'
construct the project(Sec.7044,Business and Professions Cade:)The Comacmr's Li.
came Law does not apply to an owner of property who Wilds or improve,meson,and
who contracts for such projects with a comeactor(s)licensed pursuantto the Contractor's v
Licensa law.
❑lam ase in on ,Sec. ,a&PC for mu ma son
l+'� .F' Dam (t O: 0 .
WORKER'S COMPENSATI DECLAlti
1 herebyaffirm under penalty of perjury one or the following decluetions:
❑I hue and will maintain a Certificate of Consent to self-insum for Worker's Compere
titian,as provided for by Section 37M of the labor Code,for to Kofommne.of the
work for which this permit is iuucd.
❑I have and will maintain Workers Compensation Insurance,sa required by Section
3700 of me Labor Code,for me performance of the work for which this permit is luued.
My Worker's Compsmatian Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EK EMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This union need not be completed Ipbe permit is forts.hundred dollara(SIM)
or lc'..)
I certify that in the performance or me work for which this permit is issued.l Shall not
employ any person in any mannerso sa to become subject o the Worken'ComPemation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of ON,Lahr Code,you muss
QO forthwith comply wish such provisions or this Permit shall W deemed mvnked.
z M CONSTRUCTION LENDING AGENCY
I hereby from that mem is a construction lending agency for the performs.of
x v; the work for which this permit is issued(Sec,3097,Civ.C.)
WW Q Lenders Name
Q z Lender's Addre.s
U Q I cenify that I have mad this application and Sum that the above information Is
W coned.I agree to comply with all city and county ordinances and Stam laws rolling to
Q building caa3lmCllan,and hereby authorim mpromenmtiws of this city 10 enter uPnn the
.hove-mar n mad pmTmny for inspection purposes.
cl. (We)agree to saw:,indemnify and keep harmless the City of Cupertino.imina
fg Ilabilities,judgmenu,cmu.nd expenses which may in any way...a against aid City
U In consegmncc of she Standing of this permit.
APPLICANT UNDEiRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULA IONS. II/�
ssa�- Re-roofs
neturo of ApyneanUComraetor Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant ser future Wilding Occupant store or handle hatar ore material
u nc
deRd by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
do,Section 3553$&)7 All roofs shall be inspected prior to any roofing material being installed.
' ❑Ye, �da
Will the applicant or mture building occupant up,equipment ardevima which If a roof is installed without first obtaining an inspection,I agree to remove
emit bmandous air conmrnimns as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes XNu
1 have mad the Woanhms materials requirements under Chapter 6.95 of the Califor.
nia Health&Safely Cad.,Sections 25505.35573 and 25534.1 undcmmuxd that if Use building
dues not currently how a moam that it is my responsibility to noufy the meu ant or the
regmre rats ion aatbe IPoor mison"muacem"ama�oaneY Signature of Applicant - Date
�` 7cy
0 `�C���/' t All roof coverings to be Class"B" or better
QlualTin ser authonrod agent p Oam