06100156 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C�NTRA.CTO,RNk` OATIOkV
BUILDING ADDRESS: TICO CONSTRUCTION CO PERMIT NO.06100156
10040 BUB RD
OWNER'S NAME: PERMIT ISSUE DATE
DR YUNG CHEN 1585 TERMINAL 0
Iq NE:
SANITARY NO. CONTROL NO.
(408) 499-0266
ARCHITECiIENGINEE0.:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
iOp LICENSED CONTRACTOR'S DECLARATION - Job n
Descrl on
i V Fj 1 hereby affirm Mai I am licensed umber provisions of Chapter 9(Commencing P
: m with Section 7CX))of Division 3 a(the Business and Profession Code.and my liccmc is
off infalldarc — - Q TI COMMERCIAL BUSINESS- MEDICAL OFFICE INCLUDES
m 2 Lic<mLie.N
EoDam Can,,=., ELECTRICAL, MECHANICAL, PLUMBING
' 1° ARCHITECTS DECLARATION
i z 1 understand my plans shall be used as public records
>yU
;,I3 Licensed Profn8anal
OWNER-BUILDER DECLARATION
Io
I hcrchy mTum Nm I am exempt from Ne Canuacbr's License Law for the
D O following mason.(Section 7(31.5,Business and PrefIcssiom Codd:Any city of County
c$tai which requires a persalt to Conswet.alter,improve,demolish.or repair any swctum, "
Z< prior LL)its ismanec,a1Su requires Jle appheam for such permit In file a signed Statement
thatW is licensed pursuamblW provisions of lbs Conuactah Liansc Taw(Chapwr9 Sq.Ft. Floor Area Vali$ilti6r0000
(commencing with Section 70DO)at Division 3 of Ne Burmossand Professions Cutlet or
Milk-,xempt therefrom and the basis for Ne alleged caemption.My violation of
Section 7031.5 by only applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nut more Nan BK hundred dmwa($5130) 35720026 . 00 P y YP
I,as owner of the property,or my employees with wagon as thew sale compensation,
will do the wor4 and th ndrummm is not mundW or Offered for aale(Sec.7044,Business
and Professions Code:The Constructors Lidedu:Law does Out apply to an owner of Required Inspections
property who Wilda or improwes thereon,and whodoessuchwork himself arNmugh his
owaemployera,provided that such improvements are Cot imeMed maffered!resale If,
however,Ne building or improvement is sold within one year of completion.Ne owner.
builder will ban the burden of preving that he did not build or improve for purpose of '
ale.).
❑I.as Owner of the,property,am exclusively contracting with licanad=me=On
Construct Ne project(See.7014.BLL[IneV and Professions Code:)The Contractors U.
cense law deet not apply to an owner of property who Wilds or improves thewon,and
who contracts for such projects with a co tuacbr(s)licensed pursuant to the Conhactah
License law.
❑I am exempt under Sec .B At P C for Nis mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
40 1 hereby aIDon under penalty,of perjury One of the following declamioes:
❑hart and will mainainaCertiricawaf Consembaf-insure fm Workers COmpen-
.non,u provided fm by Section 37M of Me Labor Code.for Ne Performance of Ne
work for which this permit is leaned.
❑I nava arM will maintain Workers Compeazatian insurarsce.az"Itimd by Seeman
3700 of Ne Labe Code,for Ne performance of Ne work for which Nu permit is issued.
My Worker's
sCC�o rmApesnnssationn—Inns`urance carrier and Policy number am:
Carrier. �M'CTC/T VRp Policy No.:t7010
ERTIFICA�TITON FROM WORKERS'
COMPENSATION INSURANCE 119Z90�^3
.�
(This section need not W completed if the Permit u(Drone WndreGddllan(SIOG)
Ices.)
I CUtifv Nal in Ne Performance of Inc wart for which this permit is issmd,1 shall not
employ any person in any mannerse,as to become subpet to the Workca'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to the Wohcrs Compewdon provisions of the La or Cada you most
.J z forthwith comply with such provisions or Nis permit shall W deemed molecd.
zCONSTRUCTION LENDING AGENCY
F Ihereby a(Rm that them is a construction lending agency for Inc perumrarma of
C: the work fur which this permit is issued(Sec.3097,Civ.C)
Igl Q Landers Nam,
az Lenders Address
V 0 1 cuufy Nat 1 have tend this application Cob salt that the aWve information is
U, torten.I agree to comply with all city and county ordinances and sate laws relating b
'J O building construction.and hereby authorize mpmscnUives of this city to enter upon the
0. ahovo-menuoned pm�ryms,ou for inspection purposes.
(Wee)agree to save,indemnify and keep harmless Ne City of Cupertino against
tih liabilities.judgmentseStartand oftenwsmit. may in any wayaccrue agmnslsaid City
U z m consequence of the gaming of this permit. / w
'--' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date/z — 4_zG
SOURq REGULATIONS.
lCn `) o Re-roofs
Sg ofApicanUouxbr Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
I-the appli.t m future Wilding mapat scam orhmblc havamons material
az W rued by the Cupertino Municipal Code.Chapter 9.12,and Ne Hcalth and Safety
COJC,Sccuon 25532(a)?❑Yu ANO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building amupam use equipment or Devices which an ns
If a roof is installed without first obtaininginspection,I agree to remove
P g
.mit hzvaNds oair conumin ons az defined by ftBay Area Air Quality Managment all new materials for inspection.
", ict?
❑Yes N
1 have mal the Wrardnmmateruds mquitermnu under Clapter6.95 of the Glifor-
out Heal"Safety Code.Sceipu]5505.25533 and 25534.1 unJcrsand that ifNc Wilding
does not curmn0y hast a was d,that it u my reepmuihility m pal ly thc occupant ur th.
reyuimmcnts hichmuslWmelpriorbissuancca(aCcniRcate rctCOPatey. Signature of Applicant Date
1 All roof coverings to be Class "B"or better
Owner oath rirzd agent - Dow