05030234 CITY OF CUPERTINO y= •• f r«�n ^-� " ' "-"
BUILDING DIVISION PERMIT �CONTRACT.ORANFORMATION
BUILDING ADDRESS: H T CONSTRUCTION PERMITNo05030234
191 PMPTR2 AIT
OWNER'S NAME: PERMIT ISSUE DATE
JRPRY WANG,
NE: SANITARY C NTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
(� 0 0 0
tiOo nt' LICENSED CONTRACTOR'S DECLARATION
C I hereby surto mal I am freed under and
N.I. .Guillt. 9(commencing
is Job Description
U wird Secdcot Oivision3of me Busi�av and ProfcssioMCade.aM myli<enreu
n a. in full fora and cffett
;q? License ClnaLioN REVISION--IN HOUSE USE ONLY
_, Dam Contracts, NO NEW PERMIT ISSUED ORIG. #04100049
ARCHITECTS DECLARATION
e-i I understand my plans shall the used as public mentis
JyU
it o C Licensed Professional
3 OWNER-BUILDERDECLARATION
I 1 hereby affirm That IM exempt from the Contractor's License Law for the
00 fulinwidg masd.(Satlon 1031.5.Business and Professions Cods:Any city or county
m which requires a permit to consteL alcor,improve.dcmnlish,or repair any Simonton,
prior at its issuance.also requires the applicant for such Permit to File a signed statement
< that he is licensed purmanttothe provisions orftContractor's Unener Law(Chapter 9 Sq.Ft. Floor Area Valuation $
ti (commencing with Section 1")of Division 3 of the Business and Profession Codo)or (]
'y that he is emonpl themffom and the basis for We ellsgCd exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than firs hundred dollars($500).
El 1,as owner of the property,or my employes with wages s their sole compensation. 32624057 . 00
will do me work.and the structure a not intended or offered for safe(Set.11)t4.Business Required Inspections
and Profession Code:The Contractor's License Law docs not apply m e an owner of q P
property who builds drimproves t1efeon,and who doexsuch work himself or through his
Own employees,provided that such improvements are not intended in offered for sale.If,
however,the building or improvement is sold within one yeu of completion,the owner-
builder will have the burden of proving Nat he did not build or improve for purpose of
salt.).
I,as owner of the Sen.property .Business ndus and conusning with licensed mmenvoors t. wv
contract the project apply
to So noorand Profession Code:)The Contractors cad
Co.law dins not apply i an owner of pmpeny Who buildsrm improves menton,and �^
who contracts for sato pmKcm with n cantraaor(q liccnmd pursuant to the Contractors \�
License law.
❑1 am evempl under Sec. .B&P C for this mazon
Owner Dat
73700 WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of me(allowing declarations:
him and will maintain a Cenifiam of Coneno to self-haure for Worker's Compcm
id,as provided for by Section 3700 of the Labor Code,for the performance of the
k for which this permit is issued.
I have and will maintain Worker's Coneleasadon Inurana,as required by Section
of the Labor Code.for the performance of the work for which this remail is issued.
Wprke Compensation In urana carrier and Policy numberart:
ier, Polity No.: _
ERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed i(the Permit is forts hundred dollars(SI(0)
or less.)
1 certify that in We pirformanec of the work for which this Permit is issued,1 shall not
employ any person in any manners u to become subject to the Worker'Compensation
Laws of Califomi ate
APrint.t
NOTICE TO APPLT 'T:IL after making Is Cenificam of Excerption,You Should
become subject to the Worker's Compensation provision of the Lahor Cade,you mart
.,2 foMwith comply with such provision or this retain shall be deemed mvoked.
z CONSTRUCTION LENDING AGENCY
[- Ihemby aM,m Nal mart iso construction landing.,cm,for the Pcoformance of
GYi the work for which this permit is issued(Sec.3187,Civ.C.)
D] A Lender's Name
Lender'Address
U O I unify that I have read this application and sum that the above Information is
Is. H corms.I agra in comply with all city and county Ordinances and sum laws missing to
pU building construction,and hereby au0101717e mpmacmnites of Nis City to enter upon me
r Cil shove-mentioned Properly for borectron Pmposss.
(WO)agree to save,indemnify and keep harmless the City Of Cupertino against
liabilidu,judgments,cosm and expenses which may in any way accrue against mid City
U Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
4l
Signature Admor Dem
Re-roofs
mDOUS
MATERIALS DISCLOSURE Type of Roof
Will She applicant o,furore building Occupant scam or
handle hazardous material
as defined by dm Cupertino Municipal Carlo.Chapter 9.13.and the Halt and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.❑YeON,
PWill the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑No-
1 have real the hvarddws materials require==under Chapter 6.95 of the Califor
nice Health at Safety Code.Salimu 25505,35533 and 25534.1 understand doadthe building
don not currently have a tenant thnl it is my rcxpunibility in nobly the acupam of the
fcrpimmcnm which..It bt It Yfim to issuance or a Cerdficate of Occupancy. Signature of Applicant Date
Owner or anmodP dl —� Dots All roof coverings to be Class "B" or better
Owner or mllm'��'