03120103 CITY OF CUFER'fINO
BUILDING DIVISION REKNIT CONTRACTORANFORMATION R.
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BUILDING ADDRESS: PERMIT NO.03120103 3 12 010 3
OWNER'S NAME: PERMrf ISSUE DATE
q'I
E: - SANITARY NO. CONTROL NO.
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t� t� o
�0' LICENSED COMRACIUR'S DECLARATION
4.C 1 hereby affirm In.,1 am licensed matter provisions or chapter v(commencing Job Description
<_ b with Section 7")of Divldon3 of the Bmiimssand Professions codc.md my her.is
to
S dj in full and effect.
jq_ LicenseeChua Lin ADD 99 SQ. FT. /GARAGE 218 SQ.
tl VV�I4Iay
�r1_1
g�O Ove contractor
ARCHITECT'S DECLARATION
Stzu 1 understand my plans shall M used as public mentos
t- Licemad Professional MAY l c ' 2004
`.g OWNERBUILDERDECLARATION
<P I hereby affirm that 1 am emmpt from the Contractor's License Law for the
n o following mason.(Section 703 IS,Business and Professions Cc&:Any city or county
m which mpIrmil a Permit to consumer,alter.improve,demolush,or repair any snsuctum IS/lt�J
iy poor to its issuance.also myuims the applicantfor such pmmit to file a signed statement
< that he is Reemoe pursuant to the previsions of the contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
yFD (commencing with Section 7000)of Division 3 of the Business and Professions Cook)or
i Nat he u exempt tMrtliom and one buts for Ne alleged cacmpuon.Any violation of
Section 7031.5 by any applicant for a Russell subjects the applicant to a civil penahy or 3 S+'�I9tDft2T�er0 0 Occupancy
not more Nan fin hundred dollars(S5M). P Y Type
❑I,as owner of the pmpcny,m my employees with wages as their sole eompensstim,
will on the work and the xtaumum is not intended or of r mil fofsak(See.7(144,Business
and Pmfbssions Code:no Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch workhimself or through his
own employ=,provided that such improvements are not intended moRcmd for sale If.
howcwr,the building or improvement is sold within one year of completion,the owncr
\-` build r will hew the bumen of proving that he did not build of improve for purpose of
sal
1,
as owner of on property,am exclusively contracting with licensed convamors to
I
struct the project(Sec.101a,Businm and Professions Code:)The Contractor's Li
cen law des not apply to an owner ofpmperty who builds ofimproves themon,and
whoomormob, mhpmFCut wit a contractors)liunsed pursuant to dre Contractor's
License Law.
Q 1 am carat drr, .B h P C�faar this mazon
Ow or is.1_//v�
K 'g COM SATION�gC�ICLA0.A 0 //
Ihembyaffrounder snaliyof,erjur)LRAcofthr following claret ons:
1 have and will maintain a Cerifcete pf Comem m selFimame for Worker.Cumpem
sation,as provided for by Section 37M of Ne labor Code,for the pedmma u,of the
work for which this permit is issued.
❑1 have and will maintain Worker's Componention Insurance,to,required by Section
37M of NC labor Code.for the Performance of she work for which this Permit is issued.
My Workers Compensation Insunna carrier end Policy number are:
Cattier Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
tonessaulm need nm Mcompleted lithe Permit is formte hundtod dollars(S IMI
or least.)
1 certify Nat in the performance of Ne work for which Nis Permit u issued.1 shall nut
employ any person in any manner in az to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making Nis Certificate of Eacreption,you should
become subject n 0c Worker'a Compensation provisions of the WMtr Code,you mats
.J O forthwith comply with such provisions or this permit shall M deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
I hereby aflirm that Nem is a constrvction lending agency for the performance of _
IZ the work for which this rennin is issued(Sec.3097.Civ.C.)
W Q Lender's Name
=z lender's Add. '
U Q 1 certify that I have read this application and stale that the above information is
D, F-' correct.I agree to comply with all city and county ordinances and slate laws«luting to
0 U building Conswetion.and hereby altdoom mpresentstivet of Nis city to enter upon the
move mentioned properly for impaction purposes-
Fgy (We)agree to aaw,indemnify and keep harmless the City of Curiumho against
'y liabilities.judger .costs andcapeoses which may in any way somuc.,.last to City
in mnscqucncc Nc granting of Nis rcrmit.
^ APPLICANT DER S AND WILL COMPLY WITH ALL N N.POIN'T Issued by: Date
SOUR R NATIO/.
_ Re-roofs
gig ort o AO HAZARDOUS MATERIALS DISCLOSURE mr Da Type of Roof
Will the applicant or future building Occupant store or handle harardous material
itefined by Ne Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
e.Oors Jpn zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
Will the aRNlcant or /tore ritding mcupnnt pmc use cyto t m devices whim If a roof is installed without first obtaining an inspection,I agree to remove
M1a]4rdnua is contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
Diitrinl '
Q Yes o
I hawrt halo esntverialsmquimmnuunJcr Chaper695afthc Califon
mea Health& etyC Src' m25505,25531 anJ2553d.1 understand that if the building
Ines not eto
dJy ane,that it is my mapromihility to nouly die occupant or the
mquirtmchi ntrtPous issaane racenifcamp aepean . Signature of Applicant Date
Z LT
ownerspriacdagcm „e All roof coverings to be Class "B" or better