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CITY OFCUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT N0.06050116
21762 COLUMBUS AV
OWNER'S NAME:
PERMIT ISSUE DATE
KAI MING ANTHONY CHAN
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SANITARY NO. CONTROL NO.
ARCHITECT/BNOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLO MECH
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LICENSED CONRACTOR'S DECLARATION
Job Description
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I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(118 afDivision Sof the Business and Profevmns Cede. and my license is
indRfareeandefrm
COPPER REPIPING/NEW, LIGHTING/REPLACE ALL
Dom class Lk. 00
Dam v— • fl-r-e—�Conlraelar
WINDOWS & PATIO DOORS/REMODEL KITCHEN/2 BATHRMS
DELLA N
As
mails usca
1 undersand my plana shall he uaW As public rtcorN
Licensed Professional
OWNER -BUILDER DECLARATION
I honer, sm. that I am eacmpt from to Conuattoh License I.A. far the
following moon. (Seegon 703 LS, Business and Profetsions Cale: Any City or county
which requires a permit he eanWuct. slur. Improve, demollsh. or repair any structure
prior m its issuance, also requires tha applicant for each permit in file a signed g ummem
Lame Law 9
Sq. Ft. Floor Area
Valu ill1p000
thea he is licensed pursuant to the provisions of the Contractors (Chapter
(commeuin{ MN Section 7000) of Division 7 of to Business AM Prefcsaiens Code) car
that he b exempt therefrom and the bub for the alleged exemption, Any violadoe of
p+n�+Asi 1f.,�TpTt1f5,{��
Occupancy Type
Section 7071.5 by my applicant for a permit subjects the applicant n a civil pewty of
rant mare than five dred dalura (5500).
hun
3 .7 b 18 U 4 1 T 0 0
❑ 1.uowneraf Naptopeny,wmyemployeuwiNngesuftkwlc=penution,
Required Inspections "
will do Newark and thestrucltue 4 natumndnd oroRned length, (Sm. 70M, Business
And Profasiom code: The Co uracmrs Ucca m law dote not apply m an owner M
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property who builds or improved, thermn, and who does such wart himself or through his
awn employee. provided WI such Improvements are ant intended ar offered fm sale If.
however, the building or improvement timid within au year of cempledon, the owner.
builder will have the burden of proving that les did rot build m impmw for purpose of
sale.).
Q L As owner of the property, arm exclusively contracting with licensed ConuarnR u
construct the project (Sec. 7044, Business and Profusiw Cade:) The Conuacmr's LI -
ewe law oma oat appy m an owner car propene wbo bu1Wa car improves tureen, and,
who conuacu for such projects with a contsamor(O licensed pursuant In the Contract
'
License law.
❑ I am exempt under Sea .B l PC fm Nb mason
u Dau
WORKERS COMPENSATION DECLARATION
'
1 hereby affirm under penalty of perjury ane of the fallowing declarstione:
Consentse fm Workefs Compes-
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❑ Sham and will maintain aCeNOou of self-umm
;
titan, As provided far by Section 7700 of the Labor Code. far the parformmce of the
wort for which this permit is issued
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❑ 1 haw and will mala sin Wterlem's Compensation Imuran, u acquired by Section
7700 of the LaborCode. fmimmce afthewmkfor hichthbpmmiti isseacd.
My Worker pensatio eartefand Polity number are:
-
Carver.xkJ.«JI Policy No.:
C CATEI( OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need notleccomp mod if the permit ufarom hunAeddaOao (SIM)
mleu)
1 cerdfy dot in the of the work fm which this I. issued, l shall Wa
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purmman Permit
employ any person in my msftl� o_m bcram�mbc%ta the Workers' Compensation
,s �
Laws of Califmmia Dam xS /i
Applicant/ -b
NOTICE TO AP�' Pte(, aflaTmakfing tis CeNRom of Exemption. you should
become subject n the Wof es Compensation provisions of the Lahr Code, you mug
.-
faMwhe comply with such previsions our this Permit "I Im deemed revoked.
CONSfRLENDING AGENCY
acION
I herby glum Nm His ere u a uumutinn Sending agency for theperformanceof
lad (Bee. 7097, Civ. CJ
the work lm which this parent, isve
Landes Name
Lender Address
I cmtfy that I haw mad this application And sum that the above information is
corom 1 agree in Comply with all city and county ordinances and rote laws relating la
Wilding convection, W hereby authodm representatives of Nis city to enter upon the
( above-mcnduned property for imPmction purposes.
(We) ague to saw. indemnify and keep Scanning; the City of Cupertino missing
i Iimilides, judgments• costs and expenses which may in my way seems a{almt mid City
in consequence of the {railing of this Permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Si{nuu-o pplian�f5eritraerm Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding aavpmtsmm or handle haurdom maurul
As dcOned by the Cupertino Municipal Code. Chapter 9.11. and the Health and Safety
adc. Seeder u771(a)7 /
Y. $Na
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant car furore building acceptant use equipment car deviceswhicM1
emit huardmw air cenumetanu u defined by the Bay Area Air Quality Management
all new materials for inspection.
Distinct?
0Yes $Nu
1 how mad the haurtlnes materials requirements under Chapter 6.95 attire Caliper.
nu HalthBSafuy Cada S=6=MSM.15557aM155N.luMemandthuifthe Wilding
does rut currently haw a tenants Nat it ls my rospomihlihy o nmil'y the attupant lir Nc
requirements which mag be niuuan a fa Certifuamof Occupancy.
Signature of Applicant Date
7-77'06
All roof coverings to be Class "B" or better
Owner or authorised agentDau'