04040048 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,�,CONTRACT�OR-�INFORMATIO.N ,
BUILDING ADDRESS: PERMIT NO.04040048
OWNER'S NAME: - PERMIT ISSUE DATE
•YU-JEN WU
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
trop LICENSED CONTRACTOR'S DECLARATION Job Description
mp I hereby affirm shat 1 am licensed under provisions or Chapter 9(commencing
�iW with Section 7000)of Division 3 of the Business and Professions Code,and my license is
full force and effect. ADD 1084 SQ. FT .
?�i m License Clua I Lick
Dam # community
ARCHITECTS DECLARATION
1 understand my plans shall W used as public records
le JaV
a�; Licensed Pmfcsl
siona
S OWNER-BUILDER DECLARATION
i00in
1 herchy.'Co.that I am exempt fru.the Contractor'.License Law for the
i o O following reason Permit t 7(131.5.Business and Profession Code:Any city m county
K ee which its is a Permit re to mw.,alter,impasse,demolish,or mash any swdure
riot rat its issuance.also¢quires the applicant for such permit m File a sig^ed statement
ys<
into
is licensed paramount she provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
xI- (commencing with Section 7")of Division 3 of the Business and Prafca.iens Code)or
y _ Nat he is exempt sWmfmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 3APN%7ilal6er00 Occupancy Type
not mom than Eve hundred doll..($500).
❑1,as owner aDhe property,army employees with wages as their sole campenution,
will do the wera.and the swcwm is not intended or offered for sale(Sec.70a4,Business Required Inspections
and Profession Code:The Contncmrs License Law does not apply to an owner of 9 P
own employe s.preds med that
vsuch improvements
who doessuin work lsimselror through his
own employees.building
provided Nat such improvements art not intended mple.ed for ownsL
however,Nebuilding Orden of ominissoldwithinone Wild
of completion,Nepose Of
bWilder will pave We burden of proving that he did net Wild or improve far purpose of
sale.).
$,as thep of the property,am exclusively convecting with:)The Ccommunes.l- /
onstmn the Owner of On(Sec.IDa4,Business and Profession Code:)The Contrumor to
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contr.tor(s)imemsed pursuant o the Contrac.rs /
License laem i,,
❑lam pt under Sec. ,B&PC for shin reason
Own _ -� � Data
�/(+t�� �
' CORKER'S COMPENSATION DECLARATION
I hereby of irm under pemlty of perjury one of the following declarations: C?
'Ther.and will meinom a Ccnif¢me of Consent ro.elf-i_s for Workers Cumpcn- .
s.ion,u provided for by Section 3000 of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the tabor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are
Cartier. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need not W completed if the permit is fmom hundred dollars(5100)
or less.)
I certify Nal in the performance of the work for which this permit is issued,I shall not
employ any person in any manner say as in become subject o the Wodeya''Compenation
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,army making this Certificate of Exemption,you should
become subject by Ne Worker's Compensation provisions of the labor Code,you must
.J O forthwith comply with such provision or this permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY /
'rr work
Ner themis a onned(See 30lendingagency for the Performance of
7 the work fm which this permit is issued(Sec.7091.Civ.C.)
W Q lender'sName
gl. LenderAdd.
Addm.= /J
L) 1 certify that 1 have read this city
and county
and sate Nn the aura information is
W (—' coned 1 agree to comply with all city and county ordinances and state laws relating toa
p V buildingconstruction,merely herfar by maxushorimrresue utias of this city rocnter upon the
r W .hove-(We) ncd pmpery fid inpection men hs.
F LL
(We)agree to rove,indemnify and keep harmless Nc yet ra Cupertino against
h iliabilities,fence rduecosuang of this which may in any wayacc.c against said City
t.)Z A APPLICANT
of UNDERSTANDS
granting al this Permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SIE REGULATIONS.
�r7J v �� �V
Re-roofs
u tPApptic oaCtevanyor
HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future building occupant store or handle havardous material
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety
ode.Semon 25532(a)l ��aeee All roofs shall be inspected riot[o an roofing material beim installed.
❑Yes No P P Y g g
Will thea secant or revere building t use e l Or device.whim If a roof is installed without first obtaining an inspection,I agree to remove
rap d by the
yaAir Q
harardnus air contaminants u tkfincJ by the Bay Arca Air Quality Management all new materials for inspection.
Diavin? ss[[
❑Yes .Ly No
1 have mad the W ari materials requirements under Chapter 6.95 of the Califor-
nia Hca1th&Safety Code,Section 25515,25533 and 25574.1 undemund thnit if the building
Ours not Currently have a tenant that it Is my resp ospolity by nobly the Occupant of the _
regmmme hichMustbemetpoormissuanceofaCcmficofOccupany.
ateSignature of Applicant t.� Date
� b
owner or aulhC izcd agent Date All roof coverings to be Class "B"-or better