04110067 CITY OF CUPERTINO ,�f+
BUILDING DIVISION PERMIT QNTxRACTokiiNFO�MATON
BUILDING ADDRESS: DWK CONSTRUCTION PERMITN104110067
0420 CALVERT DR_
NER'S NAME: PERMIT ISSUE DATE
ROGER WANG 1646 S DE ANZA BLVD 01Z19/2005
NE: SANITARY NO. CONTROL NO.
(408) 615-1508
ARCHITECTMNGINEER: BUILDING PERMIT INFO
B(LEIG ELECT gam,pf PLUMB MECH
;Eno LICENSED CONTRACTOR'S DECLARATION lob Descrl t1 � A p O
I'�+ 1 hcmby )of that 1 am licensed under and
Pmr ns of Chapter r(commencing p nl�— 1�9
with Section and
Division Business anti Rofruiom Code,and mylianau
e�n inrmlm sander,«t. ADDITION 547 SQ FT
j J? License Clue Lk.N
3y, Dam C..[,.(., GARAGE 134 SQ FT
ARCHITECTS DECLARATION >•/ II(,�
I urdera.mi my pl shall he used as puhlic re cords FM
h O Liccnse0 Pmfcssiond t
OWNER-BUILDER DECLARATION I�`*(LLJJIw9 gpvr■g IBI'I�IMJLVJ�Ij
y 1 thereby athrm Nm I e1.exempt from the Contractor's C c:Any c Law for the
p 0
whfolich
swing ares a Permit
so co L5,Business and Improve,
de io ll h.or:Any city or county
cture
$� which rtyuira•pc,mit m mnnmcl,eller,Impmw,Jcmnlixh,or repair any prvctum
y prior to its isauance.also ovulrosthe applicant for such nditto rte a signednucrocnt
< that he is licamcd pursuant In the provisions of the Conuaidn''s Lice not Law(Chapter 9 Sq.F[. Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business and Profcesimn Code)or $100000
Bu
t he is exempt therefrom And baba for the alleged exemption.Any violation of
Section 7D31.5 by any Applicator for a permit subjects the applicant to a civil penally of ppN Number Occupancy Type
not mom Nan Eve hundred dollars(SSW).
❑I.ss owner of the property,a my employe«with wages u their sole compensation,
will do the work,and the,un due is not intended or of(ertd(anal.(Sec.7044,Businev 37518o " 1
and Professions Code:The Cmnlnctms License Law does not apply to An owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvement,are not intended or artmed fatale.If.
however,the building or improvement is sold within one year of completion.the owner.
builder will haw t e burden of proving thm he Nd not build or Improve for purpose of
sale.).
❑1.as owner of the property,am exclusively conaa0ng with licensed contractors to
construct the project(Sec.7044,Business and Professions Cede:)The Cuntramr's Li-
cense Law dace not apply b an owner of property who builds or improves demon.and
who contracts for such projects with a contractor(s)licensed pursuant in the Commons
License Law.
❑I Am exempt under See. ,BkPC for thlsrtuon
ser it Dae
W RKER'S COMPENSATION DECLARATION
1 hereby&farm under penalty of perjury one of the following d«Iustions:
thin and will maintain a Certirate of Cnnunt to self-insure for Workees Compen.
sallon,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Wurker'a Compensation Insurance,as Enquired by Section
37W of the Labor Code.for she performance of the wmk for which this permit is issued.
My Worke.CmepensW on Insannce estate,and Poli,number art:
Cartier. Poli,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the permit Is formic hundreddollars(SIM)
or less.)
I certify that in Ne performance of the work for which this permit is Issued.I shall not
employ any person in any muur an u m become subject to the Workers'Compensation
Laws of California,Dau
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cede,you must
7z forthwith comply with such provisimn or this permit shell be deemed revoked.
y CONSTRUCTION LENDING AGENCY
1 hereby aRrm that then is&Construction lending Agency for the perrurmame of
Y' ► the work fur which this permit is issued(Sec.3M,Civ.C.)
4Q I<ndcYs Name
D z Lenderi Address
J Q I certify that I haw read this applialion and sue Thal the show informniun is
y� cancel nc
I Agree to comply with all city and county oninaes and stoic laws mlating to
�U building construction,and hereby authorive epraenutives Or this city to enter upon Ne
4 shove-mentioned property for inspection purposes.
(We)agree to on.indemnify and keep harmku the City of Cupenino against
y W Iiabiliau,judgments.costs and expenses which may in any way mcrna sgaim,said City `
in Co."...of Nc granting of this permit.
APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaHAZA Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy the
pertnant future building e.Chartstmmor handle Health us ad Safety
al
u defined by the Cupertino Municipal Code.Charter 9.13,roti the Health sad Safety
Code.Section 25533(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �No
Will the applicant or furore building occupant use cquipmcnl or devima which If a roof is installed without first obtaining an inspection,I agree to remove
.,, semi,hmuNnus air contaminant,u defined by the Bay Arca Air Quality Management all new materials for inspection. .
District
❑Yea 101:!!o
i
1 have roW On hvaNtms materials 553 iamcnu under Chapard95 it the Califon
iia s nothdrrentl yhaw a tans he,it u my r and!25531,1 to ounund a vpmthe r the
Jeca not Currently haw s anmL Nn it b my raponsihility m ratify Use aevpal of the
mquiaments which most met pmeo hsuancccra Ccrtiraeorom.puncy. Signature of Applicant Date
E
� Data All roof coverings to be Class"B",tor better
Owner serOwner ser authmrivm� '