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CITY OFCUPERTINO
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CUN,T�Ii`AC'URN'iLMATIO�
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT N0.0 55 0 9 0 04 7
ER'S NAME:
PERMIT ISSUE DATE
SAMMY MOK
12/21/2005
P ONE:
SANITARY NO, CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMITINFO
BLDGPLUMB MECH
ELECT
P. O t O O
LICENSED CONTRACTOR'S DECLARATION+A•
1 W.by mill. Nal l am licensed under proviso.. of Chapter 9 (rommcndn{
Job Descrip
with Section )0110) of Division 3 of the BuaineY and Professions Coda,and my license is
/s
in full force and effect.
License Clava Lic.I
Dam Contractor
tylpyAl/ //
DEMO
'•ra�
ARCHITECTS DECLARATION
1 underaund my plana shall he used as public meet&
C00�
Licensed Professional
OWNER -BUILDER DECLARATION
V
to Law for the
I hereby affirm onn 1 am exempt from tite ConlrsctCo My
following reason. W313, Business and : c
una Cade: My city orcounty
ectal, t
which requires a permit re caruclum
alms Improve, demolish, sererepairsig any awdent
vena de
0
the
pdmmits issuance,rsu requires theapplicant for suchpermit mfilea Law(hapterstatement
IWATA.A.ce.eJ pursuant visions nftis Comrwcefs Lt... Law(CloNer9
Sq. F[. Floor Area �. '- Valuation
(COdud exa with Section of Division 3 of tit Bwimuand Prollami Cade) or
he h hemfro'IDnd
shat tanrerrom and dam bean for the clothe on. My
Any violation of
7
io
Section 31.5 b fora permit wbkcu the applicwt w a doll penalty of
airy paha. to
r
Occupancy Type
red dwl
not mon than Rve hundred dollars (3300).
than five
❑ 1.uownerafthapmpeny,ormyemploywwlthw{es.tMVmlecampewtion,
will do th twork and the aWemR lana, intended or.lrered I ... I. (Sec.7044, Busimeu
and P.fndana Code: The C.ruscmrs License Law does net apply to an owner of
Required Inspections
propenywha bulldsm Improves dareon, and who doessuchwmkhlmaelfor through his
own employees, Provided that such improvements an, ml Intended molfmad in, ale. If.
however, the building m Improvement Is sold within aro year of completion, the owner.
builder will have the burden of proving that he did not build m Improve for purpose of
salt.
1, as owner of the property, am exclusively convecting wish licensed cenraclon to
construct the Project (Sec. 7044, Business and profusla. Code:) The Contraemr't U.
.
cense Law m.upply w an owner of propeny�who builds or improses thereon. arta,
who wnw or wch prokcts with a condanm(s) licensed pursuant in dm Con.ctoes
LicenseLaw.
❑lame m der Sea, .BAPCfar Ch ia
u 5&Dole
1,WORKERSC 770th DECLARATIOTIO N
1 hereby affirm under penalty of pedury one of the following declarations:
❑ I ham and will maintain sCenlRcamof Canwmt An self-Inwm fm WorkefaCompen.
station, as provided for by Scedon 3700 of the Labor Cade. for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compeua0on Insurance. n required by Section
3700of the labor Cade, fm Ne performance of the work fmwhich this perm' is blued.
My Warkses Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need set be completed lithe permit is froom hundreddollars ($1011)
or kis.)
I certify Nat in the perromuoce of doe wart fm which this permit is issued, ) shall not
employ any person in any.water InW nwb' 1.14 ayymken' Compensation
orA `r+
Laws of Califomia. A�ga°►..�
u��k
APPlicam y-�+_y
NOTICE TO APPLICANT: If, after making this Cenilicue of Exemption, you should
become Subject W the Workers Compensation pmvlatons of the UMr Code, you must
foMwilh comply with such pmviriou or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby minim that then is a co.vuctinn lending All fmdes performance of
the work for which this permit is issued (Sec. 3097, Civ, CJ
Lander'. Name
'
Lender's Address
1 cudfy that I haw mad this application and sum shat the above Infomtnlun Is
COMM ) gree m comply with all city and county ordinances and some laws relating to
building eonsuuction. and hereby wNarim mprewnutives of thiscily to emu upon the
above-mentioned property for iupecdon purp.ei
(We) agree to save. indemnify and keep harmless she City or LLpcmimm against
liabilities, judgments, casts and expenses which may In any way seem .141mi Yid City
in corueguem fshe gnntine of this permit.
APPLICANT NDERSfANDS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date"
SOURCE 3 ONS. Ir�
O d'—
Re -roofs
,/
tulll X_ t1,I 34 Dl
sigmalum ofAppB.nVComlYct bD!—
HAZARDOu MATERIALS DISCLOSURE
Type Of Roof `
Will dte applicant ser furore bullding aceupwl ram m Mndle hartNuus material
. de0md by the Cupenln. Munic 1 Code. Chapter 9.12, and be, Health and Safety
.Sectionz5532(a)7
0Y4 No
All roofs shall be inspected prior to any roofing material being installed.
WIII future building
If a roof is installed without first obtaining an agree to remove inspection, I
P
the applicant or Occupant use equipment or devices which
emit haumous air conuminan raced by list Bay Ar. Air Quality Management
all new -materials for inspection.
Disui.t?
❑Yes Nu
I have lead dte haurdmas materials requirements under Chapter 6.95 of the Califon
nix limmiNk Safety Code.Secd.0 2550.5, 25533 and 25334.1 undcnund shat if de Wilding
dues mol rally hoar a unwl, the' its my msp.uiblllty m notify the occupu' of lie
myuim, hichmutbumet 'o . umm..racemr"tooroccmpYy.
Signature of Applicant 'Date '
V. or
All roof coverings to be Class "B" or better
Owner or authorized agent to