03090185 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �jCONTR'ACTOR INFORMATION -i
BUILDING ADDRESS: WAYNE GONG ( PERMIT NO0 3 0 9 0 18 5
:R'S NAME: PERMIT ISSUE DATE
WAYNE ONGQ9123/2003
PHONE: SANITARY NO. - CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+oo LICENSED CONntACrOR'S DECLARATION C7 O O
u C 1 hereby affirm that I am licensed under provisions of Chapter v(commencing Job Description
9<i with Section 7MMnof Dlvixion 3.f the Busmexand Pmforsiuns Cnde,and my license is
in infmlClInnerand
Lic.N
erre"
Y
),�? fu' ClREVISION- -IN HOUSE USE ONLY
=moo Dae Contractor NO NEW PERMIT ISSUED/ORIG. #01050149
2 ARCHITECTS DECLARATION
I U i understand my plans shall he used as public records
o Licensed Professional
OWNER-BUILDER DECLARATION
2<7 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
20 following reason.(Section 7031.5.Business and Pmfeasipns Code:Any city or county U
m which requires a permit to construct,alter,improve,demolish,or repair any structure
-Zy pnorm itsisemance.also requires the applicant forsuchpermiuu rile asigoed stnmmem
into that he is licensedpursuan0otheProvisionaloftheComraaur'sLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation $Q
`t-$ (commencing with Section 70f10)nf Division 3'(the B usineer and Professions Code)ser c
-
that he is exempt dem,fmm and the basis for the alleged exemption.Any violation of n'n1
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 l��f-sl-pYSOU'YI®�O O
not mom man rive hundred dollars(55(0). - AS IQ CI It y Type -
❑ 1,nor owner Of the pmpeny,or my employees with wages az their sole compensation,
will do me work,and the structure is not intended or offered for sale(Sec.7D44.Business
and Professions Code:The Contractor's License Law docs not apply to an owner of {1.){Ved Inspections
Progeny who builds or Improves thereon,and who dos,such work himself or Borough hit 101 - FOUNDA U
own employees,provided that such improvements are not intended or offered for talc.If, 102 - PIERS
however.me building or improvement is sold wi min one year of completion.oe owner- 103 - LIFER
builder will have the burden of proving that he did not build or improve for purpose of
sal'.). 104 - REBAR
❑1,ruownerofth1.(PSnleny.m exclusively commsiins with:)CTheed ppmmmrsm
ccconstruct the pro' t(Sec.70aa,Business and professions Code:)T1s conmctor's Li 105 — ANCHOR BOLTS
rtse lzw0 not apps weer ofpropcny who builds or improve intention.and 106 - SEWER & WATER
who comn< for me mjcc "the tnaor(s)licensed pursuant the Contr.nor's
License La . 202 - UNDERFLOOR PLUMBING
❑Iemc count xr .B&P C for this maspr 203 - UNDERFLOOR MECHANICAL
O 9:13204 - UNDERFLOOR FRAME
'S COMPENSATION DEC A TION
lncteb a(Rrmpn rpe'altyorperjaryan<ar
the rmlowingdecelaradmts: 205 - UNDERFLOOR INSULATION
❑ Imve.nd wt maintain Cenifiemeo(Cpnsenuoscv.intnm ror workmrlcompcn- 301 - ROUGH PLUMBING
sation,az provided y ection 3700 of the Labor Code,for the performance of the 302 .-.. TUB & OR SHOWER
work our and and this permdis . 303 - ROUGH MECHANICAL
❑1 hawwill maintain Woncewkcr's Compensation Insurance,az required by Section
37W or the labor Code,for the performance of the work for which this permit is issued. - 304 - ROUGH ELECTRICAL
My Worker's Compensation Insurance carrier and Policy number are: 305 - FRAME,
Carrier. CERTIFICATE OF EXEMPTION YFROM WORKERS' 306 - HOEDOWNS
COMPENSATION INSURANCE 307 - INSULATION
or tell.)rrhissiction need nut Kcompleted if the permit it for one hundred dollars(S t0B 308 — SHEETROCK
1 certify matin the performance of the work for which this permit is iWOd.I shall not 309 — EXTERIOR LATH
employ any person"'any mannerse as m become subject to the Workers Compensation 310 — INTERIOR LATH
Laws of California.Date
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,sfer making this Coni lems of Exemption,you should 313 - ROOF NAIL
become subject m me Warkeir's Compensation provisions of the labor Code,you muse
zz forthwith comply with such movitlnnsorthis form itshall Wdeemed revoked. 501 - FINAL ELECTRICAL ENERGY
z CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
Ihereby afnm,that hater is.Imetructinnleading apcw mirdo,Performance or 503 - FINAL MECHANICAL ENERGY
35
be work for which this permit is issued(Sec.3097,Civ.C.)
iq Lcndcr'sName 504 - FINAL BUILDING ENERG
z Under'sAddress 505 - FINAL ELECTRICAL
;J 0 I ttrree that 1 nave r is application and state met me about information is 506 5 - GAS TEST
i (•" correct.1 agree to comp 'in all city and countordinances to
y nances and state laws relating
'U buildin9conswction dhembyauthorimmpresmmativuofmiscity tocmcropen thL P
Ju, - FIN LUMB) G
C above -m r edp perry for impaction purposes.
Wc)a at rc-liSgtmnify and keep harmless the City of Cupertino against 0 8 FI L
J
Z; inti uies,ju ts. Its, dcxNnscs which may in anyway acerae againstsaid City
n onset' fm of this per mit. r�
'-` PPL) up ERSTAND WILL COMPLY WITH ALL NON-POINT Issued by: 5 % ING Date
OU ERE TIONS.
g atom /npnm. rte our - Re-roofs
A RDOUS MATERIALS DISCLOSURE Dae Type of Roof
00'11 me pplicant ser Ilion building occupant stem or handle harandous material
de d by In no Municipal Cock,Chapter 1,11,antl the Health and Safety
an 25532 ad?
pros ❑ It All roofs shall be inspected prior to any roofing material being installed.
Will But applicant or fest re building occupant use equipment or device which If a roof is installed without first obtaining an inspection, I agree to remove
Omit haurdous air commando az defined by the Bay Area Air Qualily Management all new materials for inspection.
District?
,haw re a Ntmsma 'also immcrosunder Chapter 6.95ofineCalifor-
a
alth& clyC , dem 2351), SJ3.d25534.Imumarandthutifthcbuido,
d not cu con, live 1I m oh ts m cspunsihility m nndl'y tW rupant prom
m cm
ife whichmt the nonuiss0 eeof.Ce ' 'Ie_yt Occupaa
G3 Signature of Applicant Dale
0 1 waed aico D All roof coverings to be Class "B"or better