04110107 CITY OF CUPERTINO " p �4Kz*� :aT".-^.^4x'+- ma- r,•�i �'•�:
BUILDING DIVISION PERMIT CONTRACTORINFORMATION
BUILDING ADDRESS: WEST COAST DEVELOPMENT PERMITN1b4110107
10451 GLENCOE DR
OWNER'S NAME: PERMIT ISSUE DATE
Agdbk SHUI LIU 6455 ALMADEN RXPWY 11 /17 /2004
E: - - SANITARY NO. CONTROL NO.
(408) 323-1549
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG _-ELECr_PLUMB—_ MECH_
Sicto LICENSED CONTRACTOR'S DECLARATION IOW Description
O O
u� 1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing -- p - — -" ----- ---
with Secfon 70(W)of Division 3 of Ne Business and Psufa3ium Code.and my license is
p imrurim�l ieffee /G (( 'ZZ ADD 490 SQ. FT. (BED) ./KIT. REMODEL
Licemc Glass Lia N- -/—�✓ -- - - -
i�a Dam (/•r 7 n� Lt Contractor fT'Y E- 0 ,.1✓jR D S '
na r a� ARCHITECTS DECLARATION
Y ate I understhy+ay�Ims shall be used aj fmbEQ.6et
3 � Licensed Professional -
OWNER-OWNER-BUILDER DECLARATION
4 i 4 1 tore
hy affirm that 1 am exempt from the Contractors Liecr m Law for the _
0 0 following mason:(Section 7101.5,Business and Professions Cafe:Any city or county
5.'00
$ which requires a Permit to construct,alma improve,demolish,or repair any museum 4o600 -
,;0 prior m its issuance,also requires,the applicant for such Permit rile a signed statement L
_.F_2< _.�_-____. -
that W is licensed purisam to the previsions of the Comracmri Littmc Law(Chapter v - ---- -sq.-Ft. Floor Area Valuation -
�FG (commencing with Section 7")ofDivision 3.fthe Business and Professions Cade)or - — —_-
i $ that be is exempt therefrom and the,basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of et0 0 Occupancy Type
not ream than Ove hundred dollars(3500).
❑1,uowner of the property,or my cmployus with wages is their sole compensation, /\
will do Be work end the atmcmrc is not amended or offered for sale(Sce.701x,Busames,
and Pmratowns code:The Cmeacters Liamse Law does not apply to an uwnu of _ _ ._—. Required Inspections •�
property who builds orimproves thcrcon,and who doessuch work himeefor through his
own employee,pmvided that such improvements are not intended or offered for=Is.If. -
forwent,me building or improvement is Said within one year of completion.Ne owner. _ _ _ 1
Wild.'
will have thWomen men of proving that M did not Wild or improve for puryoti of p�
sale.). -r /V
1,as Owner of the property.am exclusively contracting with licensed contractors to - / s�P ��
construct Ne pmjea(Sec.7(44,Business and Professions Code:)The Contractor's Li-
crea,law doe not pply to an owner of Properly who Wilds or improve thereon.and L t �7 (r, lt//✓✓
who contracts for such projects with a contracmr(s)licead pursuant in We Convecmh
Line: Law.
❑I am exempt under Sec. .B h P C for this
L t
Owner Date y
WORKER'S COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury one of thc following dulsoations:
- l have and will maintain a Certificate of Consent to self-insure for workers compere
sation,as provided for by Section 37M of the labor Code.for the performance of the _ _ -
weak for which this permit is issued
❑1 have and will maintain Workers Compsh anon Inwrana,as required by Section
3700 of the Labor Code,for on,periormancc of the work for which this permit is issued.
My rkcrt lC.n.n1BnsanInto
ic inmc
Carrier; Polcy._ R�KE: �
CERTIF1CATEOFEKEMPf10NFROMWO
COMPENSATION INSURANCE "c' p1
ptI fp Ip
(This Section need not be completed if the Permit is for one hundred mllars(31 )
or leas.) .
1 cenify that in the performance of the work for which this permit u issued,I shall not
crop].;any person in any manner an a to become Subject o the Workers Comamom on
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject in the Worker's Compensation provisions of Ne labor Code,you must
�Z forthwith comply with such provisions or this Permit mail W deemed revoked.
7—C)
CONSTRUCTION LENDING AGENCY
F� l hereby affirm that then is a Construction[ending agency for the Performance of
!Yi M
the
work for which this permit is issued(Sec.3097,Civ.C.)
f[] Lender's NmM
G Z Lender's Address
() I cenify that 1 have mad this application and sum met the above information is
0 cormn.1 agree ct comply with all city and county ordinances and sum laws r upon t e
V movengcmioned Construction.and hereby forimecuorn pereosseS. Lives of this city 10 enter upon the
W shove-(We)agree
to bertySave forimnify an keep ex
(—'y
(We)agree to save,indemnify and tech harmless the City of Cupertino against
y inconco,judgmf th.ceuand of this emit. may in anyway attme against and City (/
U mc.nsequcncc of the granting of this permit
^ APPLICA UN RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date '
SOU C EGU ONS.
7 0 %a�
Re-roofs
S' nuurt of ApplicanUComescmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building occupant store or handle hatemoua material
as dcMed by the Cupertino Municipal Code.Chaper 9.12.and the Health and Safety
Code,Section 25532(a)7
D Yon �*/�o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or furore building acupom use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
1 . it harardnus air conmmmaou defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have mad Ne be amtnsmvcria]s requiremenm under Chapmr 6.95 of the Califon
.is Hcalth(k Safety Cod,Sceuom 25505,25533 and 25534.1 understand Nat ifthe building
does non c oily h a IMOHM that it is my responsibility to nou]y this aeupant of the
reya win, oat nprior wiasaancearaccninemor`r"y. � Signature ofAppllcant Date '
o mp.6rcdagenr I Date All roof coverings to be Class"B" or better