08010005 CITY OF CUPERTINO .. '•
BUILDING TrSION PERMITCC1N'. IUC-TOR'INFORMA.TIiPN '-
:n< .. x ' INF. . <,.. ...a
BUILDING ADDRESS: PERMIT N0.
21620 FITZGERALD DR 08010005
OWNER'S NAME: PERMIT ISSUE DATE
HSIU HUR—NIEN AND TANG CHUNG— 01/02/2008
PHON@ SANITARY NO. CONTROL NO.
r
HI'IECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
o o
rd u 1 hereby affirm does 1 Am IismucE under provisions of Chapter 9(commencing
_z1 w)m Section 7000))ofDivlAon 3 ofthe Business and Pmressiune Code,and my license it REMODEL' RITCHEN(130SQ) & BATH (32SQ)
w in full force and efl L
inj License Clan Lk.g ._
a, Dam Consracter
pARCHITECTS DECLARATION
K a 1 understand my plans ahall he used As public mcords
:tyU
5 tad Licensed Professional
H OWNER-BUILDER DECLARATION
E I hereby Affirm Nat 1 Am exempt from the Connectors License Law for tier
i m O following moon.(Section 703 1.5.Business and Propulsions Code:Any city or county
S a which requires a permit to cnnsruc4 alert improve,demolish,or repair any structum
prior to its issuance,also inquires tie applicant for such permitmfile aaignnl aummenl
that he is licensed pursuant to the provisions of the Canlmlms Leman[a W_ Sq. t. Floor Area $ Valuation
~$ (commencing with Section 7100)of Division 3 of NC Business and Profession Code)or 30000
that he is Bumps therefrom and the bub for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit aubjecu the applicant to a civil penalty of
notmam men five hundred dollars($500). 32647005AUbT Number Occupancy Type
❑I,u awmr of the pmpmy,m my employcu wise mgr u Meir sok eempenadon,
will do the work,and meamcmre is notinkhWed m offend(orale(Sec.70aa,Buaiws
and Prefesalon Code:The Clu me te,License Law dna ma apply m an owner of Required Inspections
propenywhc Wild.onium uwt thump,and wWdcessueh work hisuelf or through his
monemPlOYms,provided mat two improvemanu are not intended oroQereA for We.If.
however,me building m improvement is mid within ore year of completion.me owner /f/ r {7�P�'[ /�U xSI�'� 5�7_3
builder will haw ole burden of pmving that he did not build or improve for purpose of
gI
I.AS nomer of the Progeny,am exclusively conhacting with licensed conuauors It
3
street the project(Sec.7044.Business and Profession Coale:)The ConuaemrS U. p
Liner law dues not apply b an owner of property who bulida or improves meteor.and SAN ���� gJwho eonmeu for such ptojeeq with A cenuacmKs)licensed Putman,to me ContractorsYUu*/Lkenu Law.
❑I am exempt muder gee B&P/C for hs mason
Owner / aL,iM M �- Dare f _ 10011
RK R'SCOMPENSATIONDECLARATION y/s�ly
I hereby afrim under penalty of perjury ane of the following dilatations:
1 haw And will maintain A Canifteate of Cansem m Ulf-sum fur Worker's ComPeo-
'on,As provided for by Section 3700 of um labor Code,for me performance of the
F11
for which this Permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,as required by Scullin
3700 of me Labor Coda,for the performance of the work for which this permit is Wood.
My Workers Compensation surance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or leu.)(Dib motion need not le completed(file permit la for an hundred dolhom(SIg)
I coni[that in the performance of mO work for which this Permit is hived.I shall not
employany gena"many manmrm m become 4ubjutm me Warken'Compensation
Laws
of CARfomla.Dam
Applicant Lff
NOTICE TO APPLI A :If,after making this CerrlReate of Exemption.You should
become subject m the Workers Compensation previsions of she labor Code,you mail
.JO faMsons m m
with comply with h Provisions this permit shall be deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
[-+ I hereby alarm that them Is a construction lending agency for the performance of ,
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the work for which this permit is issued(Sea 3097,Civ.C.)
Q Lenders Name
Z Lueders Add.
U Q 1 certify that 1 haw teed this Application and sum that the above information Is
ry P Curren.l time to comply with all city and county ordinances and atate lam Waling to
CU building convection,and Worbyauslum,mpmunmdves ofthis city to cmerupon the
y CA above-men0rned ms,propertycosts
ford inspection purposes.
L„y (We)agree to use,indemnify and keep handlev the City of Cupertino against
UZ in
uthis atat pemiicit they in any weyamtte against cold City
61z in conxgueme of the Sransing a(thisprnnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date I--
SOUR RGULA770N5.
Re-roofs
Btgnat mofApplisumMon for Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom orhandle huardou material
As deRmd by the Cupertino Municipal Code.Coupmr 9.13,and the Health and Safely
Code,C3Yu 35533(a)? No All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant If a roof is installed'without first obtainingan inspection,I agree to remove
applicant or(court building Occupant vu cyvipmcot of devku which P gr
en"
"serious ahr contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
uret?
B
❑yss XNo
I haw mil the hamohmes maeriab m luiromcnm under ChApmr6.95 of the Califon
nia Health&Safety Cada Secuou 35505,35533 and 25534.1 undersand that time building
does not currently hew A mnan4 on It is my ruponihility in at,the occopmt of de
mquim c is hkhrout pnormiarumcenracemrea of Occup4 f Signature Of Applicant Date
��- �2/wo All roof coverings to be Class"B"or better
Own m��sd agent Dam' g