05100197 CITY OF CUPERTINO
BUILDING DIVISION PERMITXON'T"$gOI2IIVF'fOT.WAT O,
BUILDING ADDRESS: PERMIT NO.05100197
0277 rmn WAPRCR AV
OWNER'S NAME: PERMIT SUE DATE
YUNG CHEN 01/06/2006
NE: SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30, LICENSED CONTRACTOR'S DECLARATION 7obDescri tion
1 hereby afRrm Nat 1 am limy under pmvisi m of Chapter 9(mmmenciA{ p
wiNSection7IX1D)ofDividan3oflhe Business Sebe Profcaciunx Code.and my license is
m0sne Class Serra'• REVISION-BEAM & RAFTERS REPAIR/RETRO FIT
a D.to Class Lie.«
D.w cenDECL AFTER FIRE-IN HOUSE ONLY-NO NEW PERMIT
ARCHITECTS Stood
DECLARATION
IundersaMmyPlauthulbeuudacPublic rtrnrd ORIG PERMIT 05100137
D
Ap� Licensed Professional
A^ OWNER-BUILDER DECLARATION
4 M I hereby 4fli m that I am exempt from the Contractors License law for the
K 0 o following re,sun.(Section 70314,Business and Professions Cock:Any city or county
S$E which requires,Permit to entuWet,alter.improve,demolish•or mpoir any unwore
�Sn prim tons machosee,also requires tiwapplicant for such Permit to rile A signedsumment
FF< that he 1,11,ensod pontoon,to the provisions of thoConuractor's Liccom Law chapter 9 Sq.Ft. Floor Area Valuation
3� (commencing with Section 7000)of Division 3 nrthe Business and Profession,Cone)or h0
B Nat hr:is exempt therefrom and the bum fm the alleged exemption.Any violation of Y
settles,7031.3 by any appucanuar a permit Subjects the applicant to,IMI penalty of APN Number Occupancy
rot more um 0w hundred dollus(M). P y Type
❑L So ewner of the property,or my employees with"Scam theirrole crempenution.
will In,the work,and the,wnure isnot intended or offered fersale(Sec.7044,Business Required Inspections
and Pmfnssthns Code:The Convectors License law dos not apply m an owner of q p
properywhob Idorimprow thereon.and whodauuch wart hteselfor through his
awn employ .provided thaimhlmpmwmenummlinmtbWooQemdfo We.lf.
bowew, 'Idng orimpmwmmtis seldwi isnot 3ld or mproefor the owner.
builder w haw the buNan of proWng Net k did not Wild or improv far puryom of
Ie.),
1 owner of the property.am exclusively contracting with licensed contracture m
cam LA the omject(Sec.in a. Bnsinevand ny.whoons Code:)IprCanr,etoea and.
cense law dote not apply to m ownv o(prvpenY.wbo build,or improv thertan.and
who toEE
c wi mmiactods)Ilcemad pursumto the Corrientes
Lleenw
❑tom ,B&PCs rlhl mus
her Due
ER CO PENSATION DECLARATION
I hereby urirem under penury of perjury oro of the following dal tions:
I ham and will matnuin a Cenlficate of Consent to self-imam for WtedoeSCompem-
notice.an provided for by Section 3700 of the labor Cade,for the perrormanco of the
wads for which this permit is tactics.
❑1 have and will maintain Workers Compeuatlan Issuance.u tequirtd by Secdom
3700of the labor Code.fou Ne perfomame or the wok fowhich this permit is Issued.
My Worker's Compensation Insurance caller and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thmsecttm need rmbecompleted if Mep iliferonchundteddollare($100)
or Man) Q � � •
I certify Not In the per(urmSnro of Jct wdrk fa wl�ch Ihfucr�tlt u issued.l,hall nm
employ any person in any manner m tato e t .eters Campens,tian
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.IL k crti0caw of Exemption,you should
become subjw to the Walter's Coope Ileo provisions of the Lahtu Code,you must
.J O foMth m
wtmPly with such provisions m this ticem
permit shall be med wuad.
Z'-" CONSTRUCTION LENDING AGENCY
(-s o-N+ I hereby u0ren tot them is a construction lending agency for the performance of
CL the work for which this permit is issued(Sec.3097.Cin C.)
G~n. Lender's Name
7 z Lender'sAddrus
U0 1 cedfy Wt 1 MW mad this aPPEcuton and Saw this the Sinew information u
Dr Inrmet.l Alms to comply with all city and county ondinaau and sate two relating m
O building construction.and hereby authoria representatives clods city m enter upon thc
W above-mentioned property for Inspection purp=L
G (We)agree to Saw.Indemnify and keep harmless the City of Cupertino Against
In Imbibtks,Judgments.cuts Me expenses which may in say way accrue against Sold City
UZ tneomaequnee of Jct ranun of Nis perm it.
'-' APPLICANT UND SAND WILL COMPLY W TH�ALI�NpN�01rtT Issued by: Date
SOURCE REGUL 0 S ll��////VV//1s O '0
Re-roofs
Signature ol'ApplicantlCooloodor Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futom building occupant port or handle haeartlou material _
as dented by Nu Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
CoJc.Sc yes 33372(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑dont
Will the,Ppl"_,ar r WiId.ng occupant u e equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Aaysrdnul air concerns u defiad by the Bay Ama Air Qutlity Manalement all new materials for inspection.
District?
Yen Nu
Thaw real ehv{{{ggq1111wsmawrials requirements under enter .95o ifor-
oiaHulth&Safe. e. d�em3s3o3.3s333andsss34.Imaeratenduaifft ildin
Jos not cunenti)ha I m t.Net it a my remonsthilty ratify the o yp q(�d e
requmonermwhi rotabm eta tianmoraC• awar \y I�lrv/t IU Signature ofApplicant Date
Ownerar,uthoPovrA Ogen Dam All roof coverings to be Class nBn or better