03050018 COPY Otp CUPER"I'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION fi
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BUILDING ADDRESS: PERMI T No.03050018
R'S NAME: PER v[IT ISSUE DATE
MING CHEN
PHONE' SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION
or I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
aW with Section 71XV)ofoiviaon 3 orthe Business and Profession Code.and my license is
in full force and erre" ADD 2014 SQ. FT/REMODEL
;._ License Class Lic a
F o Dam Cmmmemr
ARCHITECTS DECLARATION
i 1 understand my plans shall W used as public records
ayU
h Licensed Professional
ed
OWNER-BUILDER DECLARATION
Ja Y I hereby affirm that 1 amI.S.exempt from the Contractors License Law for the IVB
00 fallowing reason wobit t ]on Lr,aftesx and improve.
d ainns Cale:Any city or county
e /
m ux which its iiru a permit re continuer,aper.Improve,demolish,fi repair ed statement t2i poor In i6 issuance.also mquir¢rhe applicant for xucM1 Permit 0leasigned statement
< that he is licensed pursuanttothe previsions ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
rhe (summoning with Section 7")of Division of the Business and Professions Cock)or
a;$ that he is omp l thcr fora and the basis for the alleged exemption.Any violation of 32612060 . 00
Section]031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mere than Bvc hundred dollars(S5W).
❑ 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the shuaure is not intended proffered for sale(See.7BQ4,Business
and Precessions Cade:The Contracture License Law docs not apply to an owner of Required Inspections
property who builds or improves themon,and who docs such work himselfor through his
own employees,provided that such improvements arc not intended oroRered for mk.If.
however.Ne building or improvement is sold within m¢year of completion.She owns
builder will have the burden of proving that be,did not Wild or improve for purpose of
Safe.).
as owner of the progeny,am exclusively contracting with licensed contractors to
contused the pmjem(Sec.7044,Business and Professions Cale:)The Contractor's Li.
se law dues not apply I. rove
an owner Of properly who builds or imps thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
Lic,i La,
lam exempt up der Sec.' .B&P C for this reason
t Date
®r WORK ER'S OM NSATION ECLARATIO
1 hereby alBrm under penny of perjury on of tM following declination:
❑1 have and will maintain a Certificate of Conenl to self inum for Worker's Compcm
ration,on provided for by Section 37W of the labor Code.far the perfotmonce of the
work for which this permit is issued.
CD I have and will maintain Workers Compensation Insurance,u required by Section ,
37W of do Libor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rpossectin need not W comported If IW Icnnot is formic hundred dollars($100)
less.)
1 sentry that in the performance of the work for which this permit is broad,1 shall nut
moony any Person in any manner sat as in hecpme subject to the Workeri Compensation
Lawn of California.Date
Applicant
NOTICE TO APPLICANT:II.after making this Certificate of Exemption,you should
become subject to the Worker Compensation provisions of the labor Code,you must
Z forthwith comply with such provisions or this permit shall W deemed evoked.
LO CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a construction lending agency Ior the perfurmanm of
]' the work for which this permit is issnd(Sita'.FN],Co,C.)
JU Q Lender's Name
7 'z Lender's Address
Q I sentry that l have read this application and acre Nat the Shove information is
y Fcorrect.1 agree to comply with all city and county ordinances and state laws relating to
U building Construction,and hereby authorim lepressntaeves or Nis city to enter upon Ne
G 'hove-mentioned progeny for inspection purposes.
(We)agree to save,indemnify and keep humblest the City of Cupcni no against
h liabilities,judgments,costs and IS pcnses which may in any way accrue against said City
j Z in consequence of the granting of thispermit./ Z(J �?
^ APPLICA UNDERSTANDS AND eL CO LY WITH ALL NON-POINT Issued by: Date � ZO
SOURC L 1 NS.
G Re-roofs _
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AZARGo S MA 1 LS DISCLOS RE Type of Roof �+->
Will the applicant or future Wildi In lint sere or handle moddous maufial
as defined by the Cupertino Municipal Code.Chapter 9.11,and the HcaW and Safety
�aSOV a 155J2(a)? Np All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mem building mccppanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huaurdous air contaminants a,dellned by the Bay Arca Air Quality Management all new materials for Inspection.
District') f
C]yes �j Nu
1 have mad the h rms`mMaterials requirements under Chapter 6.95 of the Cali for
ria Health&Safety Code.Seem.155115.15533 and 25534.1 understand that if the Wilding
docs net cu rcntly h a¢Bantttt�!!!hhhhaaaa i apanibility A notify the oceupsm of the
onto rats hiegmlxtpet.p6ar isman0of.CnifcauorOccupancy. Signature of Applicant Date
G C G �O O ->00
owner ser amoriac agent Date All roof coverings to be Class "B" or better