04110012 . CITY OF CUPERTINO e� w?pw�r
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .
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BUILDING ADDRESS: PERMIT N%4110012 4110012
10430 DE ANZA BLVD 175
OWNER'S NAME: PERMIT ISSUE DATE
AIL DINGCHIN TSAI 004
OrE; SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
noes LICENSED CONTRACTOR'S DECLARATION
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G I hereby affirm Nal 1 am lim,ucd under provisions of Chapter 9(commencing Job Description
< iwith Section Division Sof the Businessand Professions Code.andmylicense is
in tellforce andAffect.
TI-DENTIAL OFFICE
License Class Co.e
r Dau Conc
TSDECL
ARCHITECTS DECLARATION
1 understand my plans.hall he mind as public records - 1/
�yU 7
u Licensed Professional03 Oat I am exempt f DECLARATION
theComment
1 hareby that 11. exempt from the CantnutCo License Law for the
KOO whicwingmason. oun,t 7(31.5.Business;and vefdemoli Code:Any city structure
m which reyuiru a permit m enaswn,alter improve,demolish.m repair any swetuR 10200
w—N prior to its issuance.also requires the applicant for such permit w file a signed statement
��< thin he is licensed pursuant o the provisions of the Contractors Limns Law(Chapter 9 Sq. Ft. Floor Area Valuation
ant$ (commencing with Section 7")of Division 3 of the Business and PmfessinnsCNe)ser
— Nat he u attempt themm frnand dre basis for the alleged neemption.Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant tp a civil pcnehy of t3 Occupancy Type
not more than five hundred dollars(SSOO).
0 1,As owner of the property,or my employers with wages As chair In compensation,
will do the work,and the structure is not intended or offered for sale(Sec.70,14,Business
and Professions Code:The Contractors License Law does not apply w an owner of Required Inspections
property who builds or improves Hereon,and whodoessuch work himself err through his
Own employers,provided chat such improwmers are not intended or Offered formic,If,
however,the building or improvement is sold within one year ofmmpledon.the owner-
build wi0 have UW t nNcn of proving cast he did nm build or improve for purpose of
Stt
s: 1,az owner of the propeny.am exclusively contracting with licensed contractors to
construct the project(Sec.7(344,Business and Profusions Code:)The Contrtri Li.
more,law does not apply w an owner of property who builds or improv Neuron,and
who comets(ar such projects with a contractor(s)limned pursuant to the Contiguities
Lives.Law.
❑i eon attempt under c. .B&PCfortbiarauan
0 on
Data O
WOR Eg rmeby.slim.unda`wBlSdedaralicts:
have and will mahout u t a Cenificau of Consent to self-insure for Worker's Compen-
sation,az provided for by Section 3700 of the labor Code,for the perfonnvue of the
work for which this permit is issued.
I have and will maintain COWorker's Compensation Insurance,az required by Section
3700 of the Lmor Code.for the performance of the work for which this permit ie issum. '
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hccomplewJ Rthe permit is(crone hundred dollars(SIM)
ser less.)
1 mnify that in the performance of to,work for which this permit is issued,I shall not
employ any parson in any manner so az w bootee subject to ere Workers Compensation
Laws of Califomia.Dau _
Applicant
NOTICE TO APPLICANT:If,after making this CeniOeau of Exemption,you should
Immune subject to Ne Worker's Compensation provisions of On labor Code,you must
.Jz forthwith comply with such provisions or this permit shall In deemed invoked.
z CONSTRUCTION LENDING AGENCY
Ihereby.fnrm that ft.is.roammdii.lending agency for the perfurmana of
fY ,7 the work for which this permit is issued(See 3097,Co,C.)
W Q Lenders Name
:Lz Lender's Address
U C) 1 sanity that 1 have Rad this applionion LAW SLAW Nat the above information is
t" correct.1 agree to comply with all city and county oremanms and sure laws relating to
0 buddi,mosuuction,and hereby authome representatives of this city to cnWr upon the
C above-mentioned property for iespection purpofa
e
(We)agree to save,indemnify and keep hasmlcsc the City of Cupertino against
Hret dentition.judgments,costs and expenses which may in any way accrue against said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL ONS.
2 Re-roofs
mart Apple UCOnOacto' te
HAZARDOUS MATERIALS OSU¢E� Type of Roof
Will Ju applicant or fumR building otic pa store orh nvardous material
As defined by the Cupertino Municipal Code, pun 9.13,and the Health and Safety
cade,soY�3ssu(a)+ asy/yNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or(alum Wilding occupant use equipment or Devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hd/ardoua air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
District? \\//
❑Yes NO
1 have Rad the hmommus materials myu rnments an&,Chapter 6.95 of the Califor-
nia Health&Safety Cade.Satin,nX15.35533 and 25534.1 umknzvb Naz ifNc building
dors nut currently have a tenant Nat it u my rcammitc rllity in unify f aeupant of ft
Rquirtmcnuw - musabe etpricrwissuanmofa ate prOceapaney. Signature of Applicant Dale
I L12-104f
.
Owner m amharirfJ.gem me All roof coverings to be Class "B"or better