04120143 FR�ILDING
ITY OF CUPERTINO
BUILDING DIVISION PER ,�zONTRACTOMNEORMATION -
ADDRESS: - PERMIT NOO 4 12 0 14 3 •.. .
0531 S E00THIT.T. BLVD E: PERMIT ISSUE DATE
DICE FENG HUA YANG 12 /20 /2004
SANITARY NO. - CONTROL N0. —
ARCHITECDENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
'+00 LICENSED CONTRACTOR'S DECLARATION Job Description
m❑ I Wmhy affirm that I am licensed under provisionso
of Chapter 9(commencing
iW wimSeaion7M)7ofDivision3oftheBusiness WPmf inns Code,andmylieenscis - - - - '--
�„ in fell fomeandeffect. INTER. REMODEL BATHRM/'KITCHEN — – "
S la? Licenser Class Lic.0
ZF p Da¢ Contractor �
�/ .. _
iZ'}` ARCHITECTS DECLARATION C t
C 1 understand my plans shall W used u public recnNs
uLicensedm
Licensed Pfcssional f
a0� OWNER-BUILDER DECLARATION /J`p
y 'I masa .affirm on 1am 1. .Bumps from Ne ContraclCo License law far IW �� n.0 rr�`Jam))
O 4 following moron.(Saito](OLS,Business,ous. and Pmf titre Cod,:Any city or county V// !/A^ / )
which its isss a pctmio m tai s the alcor,impmm,ticermit.ore ASig any structure `/
that hpoor o its censed e.purse n t 10 es thovisio s Or for tech Permit License
SLAW(umment +
thathewit pursuant 10 of Division 3f tCommcmriu Ponfrasw(C Code)
Sq.Ft. Floor Area�(� , _�V�vi Valuation
w. (cat bait(commencing section7")and the
basis n3Mthcegedcuand Prof ray violation
or �1/!
i�$ that he a exempt IMm(ram and the btu for the Alleged caempum.Any violation of
Section 7031.5 by"Applicator for a permit sub3ccu the applicant in Arm]penally ofN 'BerO 0 4
nm mot,man fin hundred dallara(s500). -U ��� . Occupancy Type
❑1,es owner of me pmpcny,m my cmplayco with wages as Meir sole compensation,
willdo the work,and the swctum is notimended or offered formle(See.11344,Business
ford Profession Code:Ther Cnnlracme.Li..Law does but apply It an owner of Required Inspections
pmaity who baud:or improms theman.and who does such wank himrelf or through his
ownemployces.provided mat such imprommenu Are nmimmnded unopened for We.if, _
however.the building or impmmment is sold within one year of completion,the Owner-
builder will ham the burden or proving that he did not Wild or improve for purpose of - ..
sale.).
1,As Owner of the property,am exclusively contracting with licensedcon..Ora m
construct Ne ponjcn(See.7044,Business and Professions Code:)The Canuaemr's Li-
amawdoesnotapplytoanownerofpropertywhoWildsofimpromthereon.and. -
whocontracufor such pmjecu wit a contractor(s)licensed purmanuo the ComraemYs -
Lice.Taw.
C lam esemxp.1wnder Sea .B&P C for this wan
neP� /�'�✓ Dau 2 Zu G
WORKER'S COMPENSATION DECLARM�IO1/V-/
1 hereby affirm under penalty,of perjury one of me inllawing ticclernions:
I here and will maintain aCenificateof COvensto self-insum far Workces Compcn-
ration,u pmvided fm by Section 3100 of the IaWr Code,for the pofinfri of the - ..
work for which this Permit is issued.
C 1 have and will maintain Worker's Compensation Insurance,as required by Section -
3700 of Ne Labor Code.for the pedomance Of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy NO: _
CERTIFICATE OF EKEMmobl FROM WORKERS'
COMPENSATION INSURANCE
(This section need not beeompleted if lW Permit is for one hundred dollars($100)
or I.)
1 certify that in the Performance of the work for which this penmit is issued,1 shall not
corpl0y any person in any mmner An as to become subject to tW Wormy Compensation
Law.of California.Doc
Applicant -
NOTICE TO APPLICANT:If.after making his Certificate of Exemption,you should -
become subject to the Workers Compensation previsions of the labor Code,you most
.�Z forthwith comply with such provisions or this .it shall be oriented mmkcd.
z O CONSTRUCTION LENDING AGENCY
F+� I hereby alarm mat there is a corawetion lending agency for the performance of
".� the work for which this Permit is issued(Sec.309].Civ.C.)
1 0 lendcra Name
aZ Lender's Adimss
U O 1 eerify that I ham read this application and sum teas the aWm information is
Iy f^ correct.l agree to comply with all city and county ordinances and state laws relining m
p U building eamwction.and hereby ambome mpmsenutives of this city to enter upon the
r� aMve.menatnedd property for irupenion parpoxa
fy And
the
t"ra Iope
imilidune g
Wjudgmens,costs ande)Agree to Sam.
penses which may in An waywty of =gamin sand rte
fq pen yi Any way against seitl City _ , s
his
U 7. APPnsequrnec of the granting of LICANT UNDERSTANDStANDrWILL COMPLY WITH ALL NON-POINT Issued by: Dail, yzale
f
?SOURCEREG LATIONS. Re-roofs
tureo pplicam/ConracmTHAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building Occupantamre orhandle haa�ous material
fined by the Cupertino Municipal Code.Chapter 9.12,and she Health and Safes,
7Districtl
er.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
CYes 6g Nu
Will 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
t havnrdnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
{{L��///
CYcs pON.
1 ham read the hiss dn'us\materials requirements under Chapvs 6.95 of the Califor-
Health&Safety Code,Sections 25515,25533 and 25534.1undencnd drat lithe Wilding
s not currently ham a moan,Out it is my resansibility m nuuly tW occupant of the
uiremcnuw i,n muatWmetprimmissuanceofa Cerufcate fOccupancy. Signature of Applicant Date
10 0
nermamhoiud ascot Dae All roof coverings to be Class "B" or better L>