03100212 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C,ONTRACTORANFORMATIONz
BUILDING ADDRESS: RICHARD SHWE PERMITN003I002I2 '
21840 PRRMOSA AV
OWNER'S NAME: FERMR'MUE DATE
RICHARD SHWE
E; SANITARY NO. CONTROL NO.
IF
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
aioo LICENSED CONTRACTOR'S DECLARATION Job Description
:u C 1 hereby affirm Wit I am licensed under pm 'signs of Chapter 9(commencing P
.iZw with Sm'on] )af Divixion7of the Bu4neas fessinm Cod ;Tad mylicene ix
_any o tlerr«l. I �l U' NEW 2-STORY SINGLE FAMILY DWELLING
mind
Licenu
Lie.as
SFO Dae canva=tar LIVING SPACE 3387 SQ. FT. /GARAGE 480 SQ. FT.
RCHITECTS CLARATION
'y5 I underwnJ Y pr' ghat W d public records
oats
u Livcnscd Pmfcssional
OWNER-BUILDER
p5 1 hereby affirm m 7031.5,Bu triemm�the Contmaor's License law fm me
o following mason.(Section]Corm Raines.and Pmfcmlnm h.Or Any oily os county
which reyuime a perosl to enies be attic,improve.demolish.m repair any ewcwnt
'a m thin N its lensed p.also into the Blc apPh=Nl for such Contractor's
oop Permit is Lice se Law(Chapter 9
a mat me cing Wait purstion7 the of Diaiom of the the
uacwr'snit Professions
Cod erg Sq. Ft. Floor Area Valuation
to (commencing with Snmion](Yld)the basis for of me Bminessaodm.Anyons Code)ua
i�� mat he u exempt therefrom and the buts for me alleged exemption.Any violation of $540000
Section 7031.5 by any applicator for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more man rim hundred dollars(S50%
❑1,es owner of the property,or my employees with wages as their sole compenution,
will do the work,and the structure is not intended oronemd forule(See.]M4.Business Required Inspections
and property
who
obs Code:The Contractor's License Law dog not apply lf an owner of q P
propenywyces.provided
impromsmereon,and who me not work himselformmugh his
awn employers,provided met such impmmmw t are not intended of is offenedcuma,for sale.If.
builder(,me building ar impmmmvin is said within one year of completion,the owe of
builder will have du burden of proving ren he did not Mild or improve for purpose of )
Cole.). ✓/
❑1,as owner of the propcny,am exclusively convecting with Iicemed convectors to �t J
cmtswct the es not (See.loin,Business and rty who Ire Code)The Cs demor's 7 J
arae law data r suapplych Pr man owner of prapeny who sed p or improves menton,and, /
whocontractsLia far such Projects with a contractor(s)licenzd pursuant w tk Conuacsar's
Llecnu ave.
❑I and exempt under Sec. .B A P C for this recon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hared,affirmde
unr penalty of perjuryne oof the following declaration:
s have and will maintain a Cenifiam of Contin to self-insum for WorkeriCompen-
mumi,as provided for by Section 3700 of the ISWr Code,for me perfommmc of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as rtyuired by Section
37W of the labor Code.for me performance of the wart for which this permit is issuW. -
My Workces Compemxtion Insurance cannot and Poliry number am:
Cartier: Policy No.: +
CERTIFICATE OF EKEM Pf10N FROM WORKERS'
COMPENSATION INSURANCE
minstemion wed not bo eomplmed if the permit is forum hundred dollars(SRM)
or las.)
1 ccnify ma in the performance of the work for which this permit u issued,l shall not +
employ any person many manner a as gMcomc subjca m the WmkmS'Campemati(m
Law a of Cali forms Dam^^ 1`
Applicant ��
NOTICE TO APP NT:IL a akmg this Cenifcau of Exemption,you should
orae subjeaI Workesbl morria radon previsions of the Inter Code.you must
.J o wire comply With such provisions or this perm it shall M deemed remked.
Z CONSTRUCTION LENDING AGENCY
[—
I hereby affirm that them is a comeuction lending agcmy for mw performance of
fY the work for which this permit u issued(Sec.7091.Civ.C.)
Ill Lenders Name
G Lender's Address
oz
U Q 1 ccnify that 1 ham rad this application and sate that me above information is
ly E-' cortin 1 agree a comply with all city and county 9Nirunces and sum laws mhting to
O U building convection.and hereby aummina upreenutims of mu city to man upon the
r G3.1 maim-mentioned pro cry,for inspection purposes_
O. (We)agree to um,indemnify and keep harmless me City of Cupenino against
Fv) liabilities,judgments.costs and apcnus which may in any way s=ense against mid City ///
U z in conscqucncc of me gr tingof this permit. U
APPLICANT UNDER NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULA S '� pp••
( � ��~~ ® �I Re-roofs
awre of Applicao/ContucmrDae I
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Milling mcpant store or handle hmardous material
as deflZ by the Cupertino Municipal Code.Chapter 9.12,and me Knit and Safety
=cede,sanies 2sslz(.n All roofs shall be inspected nor to an roofing material being Installed.
p Y x �"° P P Y g 8
Will ma.npfi=anlar future building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
tI huiardous air conuminmu as defined by the Bay Area Air Quality Management all new materials for inspection.
Ocie'?
❑Ycs No
I have read the hvaN,ws mawrials requirements under Chapter 6.95 or the Califor-
isHcalth&Safety Code,SeCIR 25505,25537 and 2553x.l undcrsund L.if me Wilding ,
docs not c.ne ,ly ham a tens i it is my mswmibility w nodty the mcupmt of the
mgaimmcn hiehno traw. r.CcrtkfiawofOcapsicy.0-fl Signature ofApplicant Date
f
crit. or <dagenl Daw All roof coverings to be Class "B"or better