05080005 CITY OF CUPERTINO ^z+ �carT '' %^�' % "�'''
BUILDING DIVISION PERMITC'UNTRACTOR TNFU1tMATIf1N s
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BUILDING ADDRESS: PERMIT NO.0 5 0 8 0 0 0 5
21083 FENWAY CT
R'S NAME: PERMIT ISSUE DATE
CHIN HSU 08110/2005
E: SANITARY NO. - CONTROL NO.
ARCHREC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
3ozp LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby Afflrm Nal l am licensed under provisions of Chapter 9(commencing
IZ
with Soetian 7(110)of Division 3 of Ne Business end Profeud..Code,and my license is
<< Lifell umforcaadeRmt. REMODEL--MINOR STRUCTURE CHANGE/REPLACE WINDOWS
o�nmaesa c mmem ENLARGE (E) HEADER/ADD GAS LINE /ADD LITING (23
3 ARCHITECTS DECLARA71ON
1 underaund my pines"I W used An public records — V
yen Liccnsetl hereby
affix ALC®
� U
O OWNER-BUILDER DECLARATION
•� 1 hereby.rhes Nal I em exempt from the CommunesoLicence taw for Ibe `
o O
which
re ronoa(Section 703M.I.3, t.aluas and Romsdans Cade:My city m county
5$1 which its requires,•permit re cor srto aloe improve,demnlW,or mp0f any Meront
_Z E: prior H its i licensed
p alw¢gnima lhovisio s nt oftheConnit permitConnector's
Rensle Ae Land mmmem
E <
(that commencing
cingwitpuAseantrotheprovisioeso of ft
ndPooclaw(Cheprer9 Sq F[. Flo Are pis' Valu E)B000
y mat he its exempt
therefrom,
and(h eiasis f r the
the eg eines and on.My vi Cale)or
.. Jut k b eumpt therefrom and Jv:bub far me elle{ed exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of Occupancy.Type
not more Jun Bn hundred dollars($SW). 3
❑1.u owner of me pmpmy,m my employm with urgesu Heir ale cmnpenudm, WWI
will do the work and Nestrumu a Is not mounted aroifined foruk(Sm.701/,Business
and Profusalont Code:The Communes License Law dm not apply to an owner of Require inspectionsproperty who Wild,or I mprona Hereon,Andwho does such work himself m through his
own employes,provided that such Imp row menu are not muended m oRernd for am a.It.
howaer,Ne building or improvement is aid within orc yesr of completion,me owner
iwk
wiB Nn the burden of proving Wt k did net build m improve(m puryom of
owner of t e propeny.am ealuelvely cantructing with licensed merm m u 1 me project(Sec.]011,Business ad Pcefmians Code:)The Contrmtme.LI-aw dm not apply m an owner ofproperty who builds or improves Jmreon,adntracts formuch projects with a comm etor(s)licensed puma d M Joe Coutranora
Law.
exemptundoSm. DamWORKER'S COMPENSATION DECLARATION
I hereby afBon under penslty of perjury one of Lee fallowing declarmou:
n and will mintain ACeNOcate of Courant u self-loom fm WarkM1 Compen.
uprovided fm by Section 3700 of He labor Code,fm the pr(onnan ofto for which Nis permit is intend.
❑1 have and will maintain Worker's Compensation Insurance,u required by Sued.
3700 of to labor Code,for the performamec of the work for which this permit Is Issued.
My Workers Compensation Iesunaa canter and Policy number arc:
Cartier, Policy No.:
CER 1FICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not becamp mord time perm It Is return hundred dollars(Stop)
or Icss.)
I outify Not in due perfotrmace of me work for which Nis Permit is issued,I OWI am
employ any pacer In my maoer a u m bmomembkct to JC Wokeu• mp
Coenu0on
Laws of Califsook.Dam - ]
Applicsstt
NOTICE TO APPLICANT:If,after making NB OMMUre of Exemption,you mould
become subject to the Worker's Computation pmvislons of the Labor Code,you muni
.JO formwit comply wit such powisioes m Nde
is permit thall be deemed revoked.
Z 5; CONSTRUCTION LENDING AGENCY
(~ 1hereby AM.dust Nem is.conamoseda mMinl agency for to mrfmmam of
C4
to work for which thin permit Is Issued(Sec 3097,Civ.C.)
tV Q Undoes Name
Z Lenders Address
U Q 1 certify Hes I hate rod Nb application and sum that the Alton information is
ly!' corrett i a{rs to comply will,OI city and county ordiwaces and sum laws misting in
tt'J' building avmweuan,um hembymohorim repreanutins of this city be enter open Ne
W shove-mentioned Property for inspection purpaaa
G (We)agree to un,indemnify and keep harms,due,City of Cupertino against
In Ilablliies,judgments.tests ad expenses which may in any way accrue agalesl aid City
U 7 in consequence of Nc gn"Jng of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. _ ,a
`..z Re-roofs
Slims ere m'Applican✓Contrseter Dam
HAZARDOUS MATERIALS DISCLOSURE rType of Roof
Will the applicant or future building occupant more orbandlc hazardous material
tle0netl by Ne Cupertino Municipal Cotle,Chapter 9.13,and the Halt and Safety
e. Oyu 25531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑res �J Na
Will the applicant m future building occupant use equipment m device which If a roof is installed without first obtaining an inspection,I agree to remove
I h xardnus air contsminats u defined by the Bay Area Air Quality Management all new materials for inspection.
let
El Yes AJNu
I hon mad me huanloua materials requirements underCmpmm6.95 of Joe CAlifor.
Ma Hot”SafmyCode.Secdotss25503.15533 arm 25534.I understandthm if me Wilding
IJm not currently ham A mat
e .the it b reH Amity responsibility tify Ndue
e occupant of
requirements which must be mel poor lypiance of a Ccnificamof Occupancy. S ignature of Applicant Date
Owner at authodsJsgcm , All roof coverings to be Class "B"or better