06070035 CITY OFCUPERTINO -
BUILDINGDIVISIONPERMIT ...CONriU TnR7INFQRMATIQ,N x
WE ,,,., INTERNATIONAL IND
BUILDING ADDRESS: I MR NO'06070035
1692 COLUMBUS AV
R's NAME: PERMIT ISSUE DATE
RAM F YEE 19925 STEVENS CREEK B 06
PHONE: SANITARY NO. CONTROL NO.
(408) 733-0188
ARCHr1ECrfENGiNEER: BLDG BUILDING PERMITINFO
. l� PLUMB
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i p p LICENSED CONTRACT'OR'S DECLARATION Job Description
I Ir' 1 hereby affrm That I am licensed under pmvialona of Chapter 9(commcncing
with Section 7M))ofDivhlon 3 of the Business and Professions Code,and my license is
+� ifull force and effect REMODEL 2 BATHROOMS ON 2ND FLOOR NON STRUCTURAL
? Llcemc Clan Llc.0
Dam Controml
ARCHITECTS DECLARATION
f I understand my plans shall be used u public meads
U
s� Licensed Pmfaska.1
bre OWNER-BUILDER DECLARATION
Contr ON
I hereby Affirm That 1 am exempt(rose the Canuaclor's License Law far We
-a o following wan.(Section 7031.5,Business and Profuaiam Cade:My city a County $6800
3 X 2 which requires a permit m comma.,alma imp ow,demallsh.nr repair any smuc um
-iy prim in its iuumme,do mquimsdo.pplinm forsmit permit in fileasigad summent
E G that he is licensed pursuant mthe provision ofMeContractor's Licensclsw(Charon 9 Sq.Ft.Floor Area Valuation
e�8 (commencing with Sodium 7000)of Division 3 of Ne Business and Professions Cam)or
y - that he h exempt theefram and the basis for Me alleged esempth n.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil Penalty of er Occupancy Type
.at mare mut five huMmd dollars(5500).
O I,u owns ofM Me Property.or my employees with wage as their auto ampemadon,
will do the work and the smemen is at intended m offered for take(Sm.7044,Business Required Inspections
and Professions Code:The Cooecmr's License Law dao not not apply m an Owner of q P
property who Wilda orimproves daemon,and whodassuchwork himselforthrough his
awn employees,provided that such improvements art otintended aroRemed for sale.B.
however.the Wilding or Improvement Is sold wltitinaa year ofampmtian.the man-
builder M0 haw the boded of proving that he did of bulli or improve far pugmm of
ole.).
Q I,as owner of the property,am exclusively conuading with licensed aa=.to
Constnset Ne project(Sec.7044,Business am Profusions Cade:)The Cauacmle Il
came Law data not apply to an owner of property,who builds or improves thereon,and
who contracts for such projects with aaunmmogs)licemed pursuant m the Contractor's
License law.
I sm esempt ode See .03 PC Ise this won
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Data ID 6
WORK �MP SATION DECLARATION
1 hereby afflan under penalty of Perjury as of the following dcala ndom:
O 1 have and will maintain ataruftah of Consent to self-ilium for WorkeesCompen-
ation,as provided fa by Section 3700 of the Labor Code.for the performance of the
wait for which this permit is issued.
0haw and will maintain Worker's Compensation Insurance,as required by Se .
of the labor Code.far Ne performance of tide work fawhich this Permit is Wad
My My,
Compensation Insurance candor and Policy number am:
Gmm Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE '
0Th secsia read of ba ntatimed If the Permit Is for one haWsed Oil.($100)
or Ina.)
1 certify Not in We performance of the work for which this permit Is issued,I shall not
employ cry pman In any mannerm u m baaNNc obj�l m}he Workme Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:It,Amady~Ix Ccnifam of Escrep bma,you swum
became subject m the Workees Compensation provisions of the labor Code.you mnR
O fmNwith comply with such proviAms a Mi.permit Mall lac demand rooked.
Z� CONSTRUCTION LENDING AGENCY
F-r I hereby afmm that then is a com rmth n lending agency for the lcrfuanana of
CC> the work for which this permit Is Wad(Sec.3097,Civ.C.)
W� Q lender's Name
z Tenders Maw .
U Q 1 Codify that 1 have mad this application and ohm that the tWw inflammation is
it, coned.I agree In comply with all city and county ordinances and some laws relating Ise
0U building Construction,and hereby authorise representatives of this city to enter upon the
LU above-menuuncd propcny for impemlon purposes
(We)agree to ow,indemnify and kap harmless the City of Cupertino against
tirA liiabili0a.lud5mmrah.cam and expenses which may in any way area agaimuaid City
C) in^�
APPLICANT eUNDERSTANDS ANDof the Inkallot of WILLWWILL COMPLY WITH All NON-POINT Issued by: Date
SOURCE REGULATION
l Re-roofs
Signature ofAppmanUCon ser- Case
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appllant w future WlWing omepsetstare ahanNe hasvdoa material
and by set Cupeni-a Municipal Code.Chapter 9.11,and the Heddh and Safety
e.Scotian 33131(a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yu ❑Nu
WIII a applicant car forum building oecuinaL use equipment of devise which If a roof is installed without first obtaining an inspection,I agree to remove
coiI"res:air catsminsets u defned by the Bay Amo Air Quality Moagcmcnt all.new materials for inspection.
D sue?
OYa ONO
I haw mad the hosardeas materials requirements order Chapter 6.95 ofthe Califor-
nia Health h Safmy Code,Sections 35305,25533 mull 25534.l chummed!that iftht building
data of currently haw a moan,mat it h my responsibility to notify tial=upset of me
requirements w ' meta be and prior in humane ofa CeAfteate orompmq. Signature of Applicant Date
^l " 2110ld,6 All roof coverings to be Class"B"or better
Owner m iah.ab a ent IV