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CITY OF CUPERTINO
INFUR, MATTON
'BUILDING DIVIS10N PERMIT
XON'TRACT�(�,R
BUILDING ADDRESS:
PE 41T NO. 06110144 ,
105
OWNER'S NAME:
PERMIT )SUE DATE
WESLEY WONG L HELEN YE
NE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Q t� 0 nn
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
P
I mo by affirm Nal 1 am licensed under provisions of Chapter 9 (commencing
with Seedon 7IXM)) of Division 3 o due Borneo and PrOfessiam Cade. and my liocam is
in fun forte and effacr.
BATH REMODEL, MINOR. STRUCTURAL
Limnsc Class Lie. g
Do, Cmincor
ARCHITECT'S DECLARATION
I undersand my Plans shall be used as puhire teeards
Licensed Professional
TION
R DECLARATION
Oat
I hereby affirm that 11. exempt (lam the Co License law for dm
I am ompt
feMou Co
i following mason. 703 Business and Cele: My city of county
dcouas
improve, fi epait rose swcture
re Inns alter Improve,
which requima eon emsttr
h pconeh.
sive requires the appinsof for Conn ermi0o a slaw (uumcot
triotus i,l issuance. ahno be
B Connector's ni¢nssaw(Chap¢r9
Sq. Ft. Floor Area
Valuation
ale
nsed
thatheencing ithSecuanuotheproviaioion3of and Professions Cade) or
(commencing Division, of she
with Section 70nd
3
the egad oa
Nat he u eumpt Ncrtflam and dm basis for be alleged essmption. Any violation of
toe
-3
Occupancy Type
Section 7031.5 by any applieam for a permit subjccu ho applicant to a civil penalty of.
imt mart thin firs hundred dollars (5500).
_
0 1, as osvner of the property, ar my employees wish wages az their sale compewdon,
Required Inspections
ee
will do the wart. and the swcmre is not ntended or offered for We(Sec. Tau. Business
Law donat apply W an owner of
and Prefudan5 Cade: The Canuacter's Licensees
q P
propeny who builds orimprosesthermn,and whodoessuchwork himseefor through his
own employees, provided that such improsemenu see ant intended oroRered forsde. If.
however. the building or improvement is said within am Year of compiedon, the owner.
builder will have the sudden of playing that he did not hold or improve for purpose of
sale.).
[d' 1. as owner of Ne property, am uelusively communing with licensed ===Tin W
consumer the pmlect (See. 7044. Business and Professions Code:) The Contracrar3 Lb
comen Taw does not apply to in owner of pmpwy who alibis or improwes Merton, and.
who CanVdtls far such PmfeN with a coaYX da)IICM1Yd P.M cm Cammeems.
License Law.
❑ I nm escmpt undcr See . B S, P C far Nis mason
Owner ;2tZ . Date 12,1*t.
WOR PENSATION DECLARATION
.
10 1 bercby affirm under penalty of perjury, am of the following declaradom:
❑ I have and will mdnuin aCenifsnu of Cotueet a self-iasum far Warkcr's Corepen-
"
sannn, as provided far by Section 3700 of the labor Code, far the padormance of the
welt for which Nis Permit IS Issued.
0 I have and will maintain Workers Compensation Insurance. as required by Scedon
3700 of the labor Codc, for the performance ofthe wort far which Nis Permit Is ismed.
'
My Worker's Compensation Insurance artier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not nc completed lithe Permit is forme hundmdMnae (glm)
or less.)
I C Mr. Nat in the podermeme of the wart for which this tenni, is issued, l shall oro
employ any person in any transferse az W become Subject to the Woher3 Compensation
Laws of California. Date sr4 C
Applicant ��
NOTICE TO APPLICANT: MfOr making this Ceni(cale of Esempdon, you should
become subject he be Worker's Compensation provisions of the labor Codc, you must
r fanhwitle amply with such provision as Nu permit hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby algnn"there is a comuuctum lending agency for the perform moc of
dna walk for which this .it u issued (See 3097, Civ. C.)
Leader's Name
r Lender's Address
'
1 cenify that I have mad Nis application and sure that the above infotmatiun is
' correct. 1 agree to comply with all city and county ordinances and sum laws elating te
building concoction, and hereby authodm mpmwnhuives of this city to enter upnn the
aabilitms,judg d property for inspection
(We) agreeto lova, indemnify and keep harmless the City of Cupertino against
whichpurposes.
liabilities,judgmcnu, coca andespenus which may in any way scalae against said City
in consequence of the granting of N8 permit-
' UNDERSTANDS AND WILL COMPLY WITH ALL NON
/
'ZAPPLICANT
Issued by:
-POINT
SOURCE REGULATIONS.
Date
Re -roofs
Shgnuurt of AppliunUCo uaeor Dat
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will sheapplicant M futum building Occupant store or handle deadens material
as darned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Seebm 25532(.)±
❑Yes ' Gwo
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building ueupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit haoinlaus air cilmamin.ma az dermad by the Bay Arta Air Quality Management
all new materials for inspection.
P
Dwricr7
❑Yes CA
I have real Ne Esaardnus materiah reyuirtmcnu under Chapter G95 of the Califon
nu HwlthhSdcrySavwamp12553d.1 W nelfdnbulding
dos not currently have a wnanL that it 4 MY ezpmhW amilY onoccupant of the
myuiremems which must be met Poor W msuanee of. ccrai of Occupancy.
Signature of Applicant Date
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roof coverings to be Class "B" or better
Cramer ftr��Tg�All
Owner of auNamed ag rCO. "