04020173 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR",INFORMATION. '
BUIL DING ADDRESS: IN-SUNG & YOUNG BIN PARK PERMIT NO 04020173
/NEUNR'S NAME: PERMIT ISSUE DATE
IN-S
.aNE: SANITARY NO. CONTROL NO.
p..
ARCHTTECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
� 0 0
_Oj LICENSED CONTRACTOR'S DECLARATION h n
y u C 1 hereby affirm Nat 1 am Job Descrilicensed under provisions of Chapter 9(commencing p flU\NJJALE�R=D
<Zm with Section 7000)of Division 3 of NC Business and Professions Code.and my hear.is
in full force and effect. ADD 498SQ. FT . MAYp„w(? License Class Us.N 1 0 2004
Zip Dau Contractor
ARCHITECTS DECLARATION
-t 1 understand my plans shall be used as public records
BUILDING
;off Licensed Pmrommonl
S OWNER-BUILDER DECLARATION
. a F I hereby infrm Nat 1 am exempt form site Contractor's License Law for the
0 c following reason.(Second 7031.5,Business and Porfcations Code:Any city or county
K m which myoir s permit sea channel,elle,improve.demolish,or o pmt any a...to.
mew' priormits issuance,also nquims the applicam for such pe�mitm fluasigned staumem
that he is licensed pursuant to the provisions of the Contractor's Lattice Law(Chapter 9 Sq.F[.Floor Area Valuation
pZD
(commencing with Section](100)of Division Jof the Business end Prolamines Code)or
a.W that he is exempt thanfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3@XbT4,fiMer00 Occupancy Type
not mon Nan five hundred dollars(S500L
❑Lo the worof the dor sally, remyemntende withwhad for (Sec. 044,8 sins,
will Pr the work and the structure is not irundeda Law do Tortola(Sec.7D44,Business
and artywh bu Code:The nsi uencon.and
Law dors not apply to an owner of Required Inspections
pnpeny who but Ids ar i reproves Ne non,and who tl.s such work himself or thorug h his
awneer.the building
or
improvement is
arcnot intendedmplemed formic,If,
however.the building or improvement is old within one year of romple for the one of
builder will have Ota When of proving Bret W did not Wild or improve for purpose of
sale.).
b 1,as owner of the property,am exclusively convecting with licensed commctors to
consumer the project(Sec.7014.Business and Professions Code:)The Contractors Li.
rrse law does not apply in an owner of property who Wilds or improves daemon,and.
who contracts for such projects with a crearactor(s)licensed pursuant o the Ci neasomi
License Law.
❑1 an axemp� ode ca. B&P C for this reason
der a Da
WOR R'S COMPENSATION DECLAR
1 hereby affirm under penalty of perjury,one of the fo awing declarations:
❑1 have and will maintain a Cerdfcau of Coni toulf.insum for Worker'sCompcn-
union,m provided for by Section 37M of Of labor Code,for the performance of the
work for which this Permit is noted.
1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the labor Code.for the performance of Ne work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit is future hundmddolhrs(SIM)
if,lass.)
1 certify Net in the performance of the work for which this Permit is issued.I shall not
employ anyyypecrson��n any mannerm 0 to become subject the Workers Compensation
Laws of CalilOfu6.'Dau
ApPlic rel
NC APPLICANT:If.after making Bus Certificate of Exemption,you should
beco jmt to the Worker's Compavation provisions of the Labor Codc,you most
.�z forthwith comply with such provisions or this pmmitshall W deemed revoked.
zO - CONSTRUCTION LENDING AGENCY
r. 1 hereby affirm Nat there is a construction lending agency far the Performance of
CL > the work for which this permit is issued(Sec.3097,Civ.C.)
lT] z Lenders Name
:D z Lender's Address
U Q 1 certify Out 1 have read this application and sou That the above infamatiun is f-
W correct.I agree to comply with all city and county ordinances and state laws relating to
0 building construction.and hereby amhorire nomsedmives of this city to enter upon the
>i G above-mentioned property for inspection purposes.
(We)ague to save,indemnify and keep harmlcu do;City a(Cupcnino against
UZ Iiabilitiefuence of
granting
rof this Painful. may in anyway azcmc agaittst said City
U z A APPLICANT
of the gr TAN of Nis pceWI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH A
OURCE �J�Nr�ItBN-POINT Issued by: Date
REG LA ONS.
2-?42--o Re-roofs
restore of Applicanceforbactor Data I
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanutore of handle havmdous material
as defined by the Cupertino Myni UiPat Code.Chapter 9.12.and Ne Health and Safety
da,Section 25532(.)? �/ (y All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or fumm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
if barafdnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District7
oyes k5c,
1 have mail site haraNnusmaurials requirements undcrchapurb.95 of me Califor-
niaHeeldt&Safely Code,S.uons 25505.25573 and 25534.1 understand thmifde Wilding
1.'rommay hme a tenantNetitismyresponsibilitywnotifythe.copalhfthe
catsw 'chmustWmmplmwisaoareaof.camficzuoras Signature of Applicant Date
...horiaadas t D w All roof coverings to be Class"B"or better