06040084 CITY OF CUPERTINO ��' &�•..s�'z ,- `"" " '4 "' "" 99< 's
BUILDING DIVISION PERMIT
P�ONTRACTnRAN'Ey�URMA' IQIV.
2"d
BUILDING ADDRESS: PERMNN0.06040084
814 BETLIN AVE
OWNER'S NAME: PERMIT LGUE DAM
Akk LEI TIANMO
ONE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDO ELECT' PLUMB MECH
too LICENSED CONTRACTOR'S DECLARATION Job Description
f u 1 heresy afirom That 1 am Iaocuaol under pmv oro of Chapter 9(commencing
with Smdon70110)of D'v'dose3ofthe Busies and Plofctdom Code,andmYlicensea
+'1 inrullfarmandeffe 1ST FLOOR ADD: FAMILY & LIVING ROOM 713 '
LicanuC'w ue.a 2ND FLOOR NEW: 2 BEDROOMS & 2 BATHS 561 '
Dan_
ARCIIrECr3DECLARATION KITCHEN REMODEL 160 '
< I understand my plam.Wll be used as public¢cont,
SyU
Licensed Professional
N 3 OWNER-BUILDER mDECLARATION
1 hereby emrm That 11. accept from the Contractor's License law for the
Coo fallowing mason.(Section 7031.3,Badness and Pmfndens Calc:Any city or county
<$ which occludes•portable eonswcl.cher,Immune,demolish,or repair any sWclert
prior W its issuance.ads.rtquiru thapplitsnt faf such permit W file a signed stalemcot Valuation
<
that he u m
licensed purant to the provisions of the Commute,IJ¢nro Law(Chapter 9 Sq.Ft.Floor Area
z�$ (commencing with Section 701 of Division 3ofthe Business and Pro(eashms Cade)or $289227
e _ of
Section 703.5 by�appliant fa a permit subjects alleged and do basis far che applicu t to a civil Penalty of
net mom than fine hundred dollars,015010). ONNumber Occupancy Type
❑L u eweer of ire property,army employees with"gas u theasole compensation,
will de the work,and the Nucturc Is not Intended a offered faraale(See.70ad.Badrvsa Required Inspections
and Reflection Code:The Commiserates License law,docs oat apply W an owner of q P
property who builds or isepmws drercon,and who docs each work Mmmlf ar through his
own employees,provided thauuch improvements art not intended oraacred for We.if,
however.the building or Improwmut is sold within One Year of completion,the Owner.
builder will ban the harden of poring that he did Out build or improve fw Purpose of
sale.).
kI.u mune(of Ire property.arm anclnsiwly coma shag with licensed mnaann W
o
c Iron the project(Sec.70th.Business and PmfeWam Code:)The CWUW ora U-
came taw das not apply be an owner of property who builds or impmwa decrease.and,
who contracts for such projeeu with a conuanormi licensed pursuant be the Cenmanels
Licosa law.
OlameaeYmsI da See .B k PC fa Nis maven
Owner�' —SAI 1Data0�/
I 'I
WORKHR'S COMPE SA NDECLARATI ` 'I
1 hereby affirm under penalty of perjury,arc of the fallowing dalaradons:
❑I haw and will mainmin Section
31M of me Lab W seade.fore use
erform Camf the
ceders,r ProWded(Pe hY Section 3700 of the labor Cade,far Ues perfarmarme of the
were:for which this permit Is iaued.
❑1 have and will maintain Wurkere Compeasatme Insursae.as squired by Section
3700 of the labor Cods,far the pmfafmurce of dm wart far which Wit pemdr d'Hued.
My Workers Campemadem Insurance carter and Policy numbs are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need net be completed If Ih permit Is(aone hundred dollars($100)
or less.)
1 certify that In the performance of the work for which this permit is Wood.l shall not
cmPlayanY Penon in any marmurso u W become subject to the Workers'Campces
taws of Califomia Dares
Applicant
NOTICE TO APPLICANT:If.a r making this Continues of Exemption.you tate
become subject W the Workeh Canpemdon pmvldom of the Saw y mum
.,O forthwith comply with such faavidm
ons at this permit sledl be doed revoked.
? In CONSTRUCrION LENDING AGENCY
[-� Ihercby amrm thin them Is a consumemn lending agency for the perftmmaax of
0.'> the wore for whim war permit is issued(Sec.31197,Civ.C.)
W�Q Lenders None '
Landers Address
1 cenify that 1 have reed Ws application and sure the the moa,information Is
U 6
is. Prcorrect.I agree to comply with all city and county ordinances and sate laws selating la
0 U building construction,and hereby authorim representariws or this city to enter uponthe
W ahove-mentiunsd properly for inspection putpoess.
F fY
We)agree to an.indemnify and kcep harmless the City of Cupertino against
fA
liabilities,judgments,case ares expenses which may In any way acme qdm.said City
U z in coneegvence of the gruming of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULA _ s
4 Re-roofs
Signeturc of App'ianb nor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicamor futon building decorousrorc or handle harper loas mawmt
as defined by the Cupertino Municipal Code.Chapter 9.13,and!that Health and Safety
Cad.,section 355320)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
hich
Will the appliesat or future building Occupant mo equipment ar devices wIf a roof is installed without first obtaining an inspection,I agree to remove
..It be%Ldoas eI,commemmu u defined by the Bay Ams All Quality Managcmcnt all new materials for inspection.
D suicO
0Yes 9tNo
I haw mad the hanrdam m teriatsrequirtmew under C7mpesr6.95 ofth Cdifon
.is Health B SafnyCade,Secuam 235115.25533 roti 25534.l understand leu Wdes buiWWg
does mol currently ban•esnml,that it a MY responsibility an notify des uceupmt of the
myulrtm-II+dhich must hend pdWiuuancc eof (,Catif¢'¢y00icatppumyp9 Signature of Applicant Date
l- 1Jti'^ 'j �O/j`��7 / 1V All roof coverings to be Class"B"or better
Owner or awnorbed agent a�W