03030150 CITY OFCUPERTINO �+''"` '" �%*•^ '� `" '3. ':h
BUILDING DIVISION PERMIT fCUN 6-ka"TOW . '0 a-l''o
BUILDING ADDRESS: PERMITNO.
WAYNE CHOI
OWNE PERMIT ISS
11W; SANITARY MhAOL NO.
ARCHITEC RINOINEER; BUILDING PERMIT INFO
BLDG ELECT" PLUMB MSCH
0 t�
30p
LICENSED CONTRACTORS DECLARATION JobDescri tion
O 1 hereby affirm Net I em licensed under pmvlsiou or Chapter Y(commencing p
with Section 7000)of Division 3 of the Business and Pecreulons Coda,end my license Is
n�1 in full torte and affect.
DamnseClut Cmnctm TENANT IMPROVEMENT FINALEO
7pQ ARCHITECTS DECLARATION UCSC EXTENSION
SS5 g��a Oy 1 understand my plans shell be used u public rceords
5� Licensed Professional SEP 22. 2003
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Canuacnors License Law for the
0 o following mason.(Section 70314,Business and Prefeasions Code:My city or county TING
$(r which ruches a Permit to construct,eller Improve.demm olish, repair my structure
ar prior In Its Issuance,elm outlru the applicant rte such permit to file a0iml statement
ayx< mothe is licensed pumtantto the pmvislou of Ne Conitamara license Law(Chapter 9 Sq.Ft.Floor Area Valuation
6�^ (communing with Section 7t10D)of Dividon 3 or the Business and Pmfcuinns Cods)or
3
that he Is exempt Li mfmm and the bash for the alleged exemption.Any vioutian or
Section 7031.3 by any applicant for a permit subjuu the applicant to a civil penalty of APN Number
am mom Nen Rw hundred dollars(5300). y��
❑1,as owrer of the rectally,or my employees with wages o their soh compensation. 32720025
will do the work.and the ewcmm is not intended orartmed lot ale(Sec.704/,Buim•• `
and Pecfesdons Code:The Commutes License Law data not apply in an awa x or Required Inspections O•t- ,F.;TJI
prepany who build,arimpreves thereon,andwhodoesauchwork hlmselfartivough his 101FOUNDATION `
own employee,provided that each Impecwmenu art notinwwad mortised fm ule.H, - +�
however.the building or lmprevannum It told within one year of completion,Na awaeo lO2 — PIERS
builder will Its"the burden of proving Net he did not build m borrow for purpose or v
este.). 103 - UFER
❑1,as owner of the property,am exelu vely contracting with licensed contrumn m 104 — REBAR '
common the es.m pplyw s anal PeclGnans Code:1The veanuamrau- 105 — ANCHOR BOLTS
cove law oea not apply m en owrer p y who bullda or Tmpmvas Norton.and
wboco ecu for such pmjeeuwM a mHO lteenseEparsnsnue tarCmuamob - 106 — SEWER & WATER
w.
s .BmPcrmthhrc,aaa 202 - UNDERFLOOR PLUMBING '
2 203 - UNDERFLOOR MECHANICAL
8 MPENSAIIONDECLARA 2 204 - UNDERFLOOR FRAME
0jff_-,,LW01R1KK
hereby a7rm under penalty of perjury aro of the following decanli2205 - UNDERFLOOR INSULATION
wsodfumeinuineCemOwtearConsem to scat-imam fmworkereCmnpco- 301 — ROUGH PLUMBING
minis,u provided for by Section 3700 of the Labor Cade,for the Performance of the
work for which this permit is issued. 302 - TUB & OR SHOWER
❑1 haw and will maintain Workers Compensation Insurance,u required by Section 303 — ROUGH MECHANICAL
3700 of the Labor CoM.for the performance ofthe work for which this Permit is Issued. 3O4 — ROUGH ELECTRICAL
My Workers Compensation Immn
� cp caller and Policy number tae:
Carder. Policy No.: 305 - FRAME
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOEDOWNS•
COMPENSATION INSURANCE
(nta eecu n reed Out hettmpteed lithe permit bforow hmtdreddonm($100) 307 — INSULATION
carless.) 308 - SHEETROCK
_ 1 comfy that in the performance of the work for which Na Permit is Issued,l N,Wram 309 - EXTERIOR LATH - -
employ any person lnmymamerseaewbettme subject NNewadrc.cnmpenGum 310 - INTERIOR LATH
laws of Caliie.Dam
rom
Applicata
NOTICE TO APPLICANT.If,a far making this Certificate of Exemption.you ghoul; 311 — SCRATCH COAT
become subject to the Wortera Compensation provisions of the IaMn Code,you mut 313 - ROOF NAIL
z forthwith comply with such provisions or this permluhall he deemed revoked.
zC 501 - FINAL ELECTRICAL ENERGY
Z CONSTRUCTION LENDING AOENCY 502 - FINAL PLUMBING ENERGY.
1 hereby affirm that them las construction lending agency for No Performance of
x the work for which this permit lsIssued(Sec.3097.Civ.C.) 503 - FINAL MECHANICAL ENERGY
yq
Lcnd:r`s
e
rt er,NMddm 504 - FINAL BUILDING ENERGY .
?Z
Len
Jp ICurrey that lhave rade this application andcounorisstate that the scow Information MInma SOS — FINAL ELECTRICAL
y miming l agree to comply with all city and county ordinancesoam state coumining e 6 — GAS TEST (�l([—�
building construct
ion,suahereby
ecd Pa rcprceemnivrs of Nh city menmr upon the
�w above-mentlonedpPeNonpu 0 FI PLUMB G
(Wj agree pe ep leu the anyway ac rocupedino against
yyz IIebIIlli ,judeptecnif whl mayinssUseCtyofCpamGiginst 8 FI M AE
J^t
APIn ICecnttofw mit. O LY WITH ALL Issued by: 5 Date
,,-6..00t 9 Re-roofs 514 INAL PUBLIC .WORKS
1 um o ppllc �eO J type of Roof
S Mding 0cALS DISCLOSURE
Will ytheC Cupertino
future building ht mom manndte Health hazardous material
u de.Sao].
a by the 32(a)?nn Munldpel C ,Chapter 9.13,end the HGIN and Safety
Cade.sect es usua)7 All roofs shall be inspected prior to any roofing material being installed.
pYu
WIII the applicant or future building account tae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cnannue,air cmtemRtymirms u dcy Ne Bay Ares Air Quality Management all new materials for inspection.
Daidct7 /
❑Yes
Ihawread Nebuardoumeterlahm mono uaderchepur6,95oflhe Califor.
naHeal Sarmycode Sectltau%503. 33 SN.IunderandN Ifth.building
tlaa currently s that ltl spomlb ' notify do aceuPantMNc
en i Pd Cc c u Signature of Applicant Date
Y�a All roof coverings to be Class"B" or better
orsuth cm D g