00080039 CITY OF GUPERTI O C g N'f. (; IN OO R+MA• ION: PERMITNO.
2M'!§l§� DEXTEFPIWIT @@080039
BUILDINGADDRESS:
YANG SANITARYNO@B Abp PfJ0y$}64]TfALDATE
OWNrR'S NAME. ILL C IROL#
' NIC CONTAOLp
PHONE:,
ARCHITECfIF.NGINEER Ifl11.DING f'IiRMITaIN O
U
�i LICENSED CONTRACTOR'S DECLARATION •BATH RE
MA�FDL
Z P vim]— 1 hereby air.that I am licensed minder provisions of Chapter 9(comtrcrcing ,J O escrl tl On',
Om O wish Section n000)ofDivision3ofthe Business and Professions Cade,and my It...I.
- p
y infullfomeandeRect.
Ore u°'1 Llano Clan Lie N
C..
H L+O ARCHTI S DECLARATION
Sy�y g I understood my plus shall be used u public records
ue ;i!
u a G IJcemcd Professional /
uaS 4_' OWNER-BUR.DER DE RATION /
S >' .1 hereby M.that 1 am exempt from On Cemmu me.Litems Law for the + `/
+d ¢
❑ following tribunes
a(Section 703 Boson. and Professions Cade:Any tiny or or,
�u 3 which rtquim a pemdt w catswm,Jrer,improve,demolish,or reps any sravcture 000
Sq. Ft.Floor Area nat1011
duitImi¢iused;i.w rt9uirtstha eppliumfmaoch pervutwBleaaigoed eta¢mem ,
Nen he is liccmed pursuanna Ne provisionwf Ne CurtwwYe Licenss 4w(Chaqu9
(commencingwish Swtionnand)his basis f3 use Busimuand Pro Ad,violation
r 00
WI I.is 31.5 b any Wii and or burs fits the alleged whoa on,Any viobuon of APN e Occupancy Type
noctiu ID)1.3 are any applicul rte u permit subjects Ne applicant m•civil Penalty of
nal mom Nen..,of
hundred Collar($300).
I,as owmr of Ne property,or my employees with wagsu Neinole compenutian, � 1 9 Ons '
willdo Nework,and Neeauch a is maimendedmiufferedfm We(Sec,]094,Buaineu 102 — PI RS
and Profession Cad,:The Comrwnor'a License taw does nm apply to an owner of
property who builds to improves thereon,and who dma such winds himself m thim,lb 1 @3- — UFE R
his own employers,provided that such improvements are not intended m offered for
ole.If,however she,building or improvmnent is sold within one year ofcompletion,Ne ,104 — REBAR
0Idswnewill love the burdenofpmvingthathe did nmwudorimpwreforpur- 1@5 — ANCHOR BOLTS
or of Ne property,am eaelmively contracting with licensed conhamon to 1,06 — SEWE R A WATER
construct Ne project(S.,70.4,Business and Professions Code:)The Coneacme.Li- r - -
' enaeLadoesnotappywanowner of property who bailor orr improves overrun,and 202 — UNDERFLOOR PLUMBING
who convects For such projects with a convacmr(e)licensed putout ch the Canuacmes
o`i�L m derS . B&Pcmrthiartnan 203 — UNDERFLOOR MECHANICAL
owns-' _ ' • 204 — UNDERFLOOR FRAME
u WORI(E SCo E CLARATON 205 — UNDERFLOOR INSULATION
I hereby affirm mother prtwlyof perjury ane of the murt.•ing d«l.r.aam: 301 — ROUGH PLUMBING.
❑I have and will maintain a Comficate of Comenuo selLinsum for Worker a Compete
cation,as provided for by Section 3700.1'the Labor Code,for Iha perforromes of the 302 TUB & OR SHOWER
work far which Nis permit is issued
0 have and will unions.Wodser.Compensation Insur..aa"mord bySection 303' — ROUGH MECHANICAL
3700ofthe Labor Code,for the perfmmance of he work for which Nis permit is issued. ,304 — ROUGH ELECTRICAL_
s My Worker's Compensation Insurance tamer end Policy number ue: i
Comer: Policy No.:
CERTIFICATE OFE%EMPIIONMOM WORKBRS' 305 — FRAME
COMPENSATION INSURANCE 306 — HOEDOWNS
(ThisxmlonnxdnmbecomPleW ifthe permit is forme hound dollars($100) - _
an<„') - 307 — INSULATION
I,any Matin in sen,....of Ne wort fm shin der Worth rued,l shall -
notcmplwsofCalifoniiaUses mrunmbeume subjectwNe Wodsen'Comnpcd- 3@B — SHEETROCK
union Laws of California.Dam ,
Appfimm � - - 309 "= EXTERIDR LATH
NOTICE TO APPLICANT,IL after making this Certificate of Exemption,you should 310 — INTERIOR LATH
became subject to the Worker's Compen ation provisions of the labor Code,you most
rmNwith comply wit such Provisions or this permit shall be donned revoked., .311 — SCRATCH COAT
Z CONSMUCrION LENDING AGENCY 313 — ROOF NAIL
0 Q 1henbyafOnn Mar,there is a remwcdon bending agency fusion perf.e of
the wmkfor which this Famous isiaaueffSac,3097.Civ,C.) 501, — FINAL ELECTRICAL ENERGY' ,
F. Lender,Name ;y
Le=',Addeo; 502 — FINAL PLUMBING ENERGY .
w o I ramify Ne,1 have mud Nis application and We that to above infmmauon Is 503 — FINAL MECHANICAL ENERGY
V 0 correct:I agwon,es to comply with all city and comm,atdluncea and sum Hwa relating no
building conscuand hereby uninuire,reprcrn
autiveaofthis city toenm —
ruponthe 504 FINAL BUILDING -ENERGY
abovamenti...d property for inspection purposes.
(We).pan wea..indemnify and keep harmless the City of Cupertino against 505 — FINAL ELECTRICAL
0 U Iiabilitiu,judgmems,cru aha espanus which my in any way sewn spatial said City
y w incomegmence,ofthe gmntingofthis Permit. 506 — GAS 'FEST
U Z SOURCANTIIND II.I YWfIHALL NDN-POINT' 507 — FINAL PLUMBING
SOPLICANTU DERST,ATIONS. loss
508 — FINAL MECHANICAL
naurn fApplic.n° elm DAM 509 — FINAL GRADE
HAZARDOUS MATERIALS DISCLOSURE -
WiIlNeapplicanlorfuturt buildingrccupantatnreom'haMlehazWouam.rerial Re-roofsPLANNING
u defend by the Cupertino MudciMI Code.Chapur 9.11,aha Ne Hwddi aha Salety
Cod.,Section 25532(.P - Type of Roof 514 — FINAL PUBLIC WORKS
❑Yes [3 No
Will beApplicant o,future buildingrcmmpm„use egiognernordeviceswhich All roofs shall be inspected prior to any roofing material being
emit harardoua air comamimnu u defend by she Bay Am Ah Quality Management installed. If a roof is installed without first obtaining an inspection
❑Ycs
m ' I a ree to remove all.new materials for inspection. Applicant
'�
Ihave Ne m,m❑No airousmiainementsmade,Chapter 6.95°f use Cali. un erstands and will comply with all non point source regulations.
fmnH He.ith&Safety Code,Sccuons 235(15,253JJ an 25534.1 umWcrstuJ Net if Ne v �'
huldingdoes mmoolyha mnantdua :a pomicliy to notify she occupant of m4yy��qq��^^u wNch mm nm pnanu i nee of s Cenificaw of Occupancy.
� r(L Signature of Applicant Date
o euNonzed em Dam
” All roof coverings to be Class`B”or better
OFFICE