05080265 CITY OF CUPER'I'INOs f' 5aw �#
BUILDING DtvlsloN PERMIT C0NTRAGTORANFORMATION '
BUILDING ADDRESS: K H CONSTRUCTION PERMIT No.05080265
0397 AVENIDA LN
ER'S NAME: PERMIT LSSUR DATE
IGNATIUS Y. DING 1045 SYCAMORE D 09/13/2005
ONE: SANITARY NO. CONTROL NO.
(650) 873-4878
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION Job'Descri [ionO O O O
Fu C 1 hereby,affirm Nal I am licensed under previsions of Chapter 9(commencing P�h�ll I�
-zw wiuh Scctmn]IXXpof Division Jof the BuxircuaW Professions Code.and my license is e t ''+Jd Lls�os
"`oma in full corse and effect. RETAINING WALL � � �+ek_-
? License Class Lie.A
p Date Contracmr
ARCHITECT'S DECLARATIONA_ 7005
Si < I understand my plans shall be used as public recent,
tau
sOH Licensed PmfeWonal 1t�
OW NEmexemDER DECLARATIONIIA �j'�"�, �J [R. 11 /�
.�<y 1 hereby a17rm Nm I am exempt from CL RATMtafs License Lew for IW fyv U fol'LI{t�U 1117111{jll\\\U11111 tri/`Y/J
p O following mason.(Section 71131.5.Business and PMmumns Code:Any city or county
2 m which .a permit to construct,alcor,improve,demolish,nr mpmr any umpute $30000
prior to its issuance.also requires the applicant for such Permit in rile a signed statement
< Nalhcins licensed purneentinthe provisions ofbeColoration's Lisex Law(Chapter 9 Sq.Ft. Floor Area Valuation
yHa (commencing with Section70DO)of Division 3 of the B usiness and Professions Code)or
y
but he IS eaempl therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjeca be applicant to a civil penalty of
not mom men BK hundred dollars(s5(B). r Occupancy Type
I,As owner of the property,or my employm wit wages as their sole compensation,
will do to work.and the structure H not intended or offered for sale(Sec.71114,Busubasts
and Professions Code:The Contactors Li«tae Law does not apply m an owner or Required Inspections
property who builds or improves tcmon,and who toes such work himself or trough his
Own employees,provided that each improvements arc not intended oroUered for We.If.
however,the building or improvement is sold within am year of completion,the owtter-
builder will have the burden of proving that he did not build or improve for purpose of
ra.1
/j
I.as t IM project of the proRny.am esne siv nd confessions with:itched convenors i.
cerin La the esot (Sec.7044.Business and Professions ds or Code:) Convector's nd
ceras Taw does not apply m ts owner of property who builds or improves themon.Coope and.
whoa.Lace for such projects with a eantrssmr(s)licensed pursuam to the Contranoh
License Law.
slam ea rept under .B&qP furl smawn
I W' Dam-1 t1 n.pa
\s
WORKER SCO
AnON ECLARATION
l lertby aRrm under pcnils fperjuryo the following declarations: .
1 have and will maintain Cenit .of Cnnunt to self-insurefarWorkersCompen-
sation,u provided for by Section 3]W of to labor Code,for the perfoonance of the
work far which his permit is issued.
1 have and will maintain Workers Compensation Insurance,u required by Section
37W of due labor Code,for to performance of the work for which this permit is issued.
My Workers Compensation Insurance carom and Policy number art:
Cartier. Pol icy NO: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tess section need not W completed if tin permit is forene hundred dollars(810)
It..)
1 cenify that in the Performance f the work for which tis Per )) is issued,1 shall not
an
employyper nary mm a mean becomesdjmiw gots Compensation
Iawsof Califon !Dam '4
Applicam
NOTICE TO P IC NT:If.after in ki rs Cenifie of Exemption,you should
become suhjc m be orkerS Compc on pmvuions f tine tabor Code,you mum
Z foMwit comply with such provisions or his Peter Pershall decmd cooked.
z CONSTRUCTION LENDING AGENCY
I hemb afRrm than tort is a construction Lending[— y g ascrcy for to perfurmance of
C' the work fur which this permit is issued(Sec.7097,Civ.C.)
f21 Q
Lender'sName
a' LcndeiAdds Atldress
D
V Q I certify that I have mad his application end zinc Net to shove information ix
F' tartan.1Alma ecomply with all udyand mpresoNinmcesad sum laws relating m
V above mentioned roAnd hominytopurposes. msof tiscity lin corer upon lM
C[l alrovr(We)
property for inspectionnifkeep h.
F' IS. (Wc)egrte m save,indemnify and keep harrnlcss tc City of Cupertino against
(n liabilitica,judgmcnts,<osts and expenses which may in anyway secret against said City
C)Z in consequence of to granting of to permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P01 Issued by: Date
;istrinctl
EGU
A y ' Re-roofs
pplicanVConva<mr Dam
HAZA MATERIALS SCLOSURE Type of Roof
theapplicant r future one,
Occupant atom or handle ha�ous material
y the Cupertino Municipal Code,Chapter 9.13,and the Heald and Safety
n 25572(a)? All roofs shall be inspected prior to any roofing material being installed.
the Applicant or comm building occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
pp 6 p Area
uardeviceswhich
us air contaminants u Jcf9W by the Bay Arta Air Quality Management all new materials for inspection.
c(H/
❑Yes
1 have red Ne baraNnusmatcrialsmquirements under Chapier6.95 ofte Califor.
ria Hcelt h SafetyCoi Semons25505,25573 and 35534.1 understand tatifine Wilding
dos not temerity ha a tcnenl tat it is my respomihility W Mindy the necupent of
mgmm is AK metpnarmimaareceMraceni0va ara-uparty. Signature of Applicant Date
t All roof coverings to be Class "B"or better
Ownc rant an.d agent Dam