06030006 CITY OF CUPERTINOs -n+ s- 4M
BUILDING DIVISION PERMIT tCOTRACT,URI `17RMTIN
BUILDING ADDRESS: _ PERMIT NO.0 6030006
19944 HOMRSTRAT) RD
OWNER'S NAME: PERMIT ISSUE DATE
WAYNE GONG 03/03/2006
E: SANITARY N0, CONTROL NO.
AREbmT.CT(ENGINEER: BLDG BUILDING PERMIT INFO
ELECT PLUMB MECH
l� l�
30o LICENSED CONTRACTOR'S DECLARATION JobDescrison
ifsed 1 hereby affirm Net 1 am licensed under provisions of Chapter 9(commercial, p .,
a� with Section 7")omMslan 3 ofde Business aM Profession Code,and my license is
in foil Toren a ad effaet. DEMO- RESTROOMS/REN TO ADA APPROV
License Class Contractor
LTO
3 Dare 7175 DELL
ARCHIW use DECLARATION
Q I undersand my plan slWl be used m public records
k C Licensed Professional 1000 .
OWNER-BUILDER DECLARATION
E D O hcuby affirm on 1 1. exempt faro the Contracror's License law for Ne
0 C following renin.(Section 7031.5.Business and Profrssiun Cade:My city or county -
$ which inquires a permit to cenprum,alter,improve,demolish,or repair any structure $8000
_ S^ prior m its issue=,aim requires pre applicant for tech permit file a signed statement
€� that he is licensed putwent m the provision of the Conuacar'a Licemc Law(Chap=9 Sq.Ft. Floor Area aluation
$ (commencing with Section 70D0)of Division 3 afthe Busseaand Professions Cade)Or
that he Isexempt therefrom and the bests fa the alleged nrmplion.My violation of
session 7D31.5 by acy applicant for a permit subjects the applicant m a civil Penalty of Occupancy Type
not mote than five hundred dollen($500).
❑1,u oars'of tit propmy,or my employm with"race u thetr mle compenudon.
will do to work and the avucwrt)s noUntendcd proffered far Mm(Sm.7044,But. Required Inspections
and profeavmn Code:The CutMnrl at License Law dors tapply m an Owner of q P
prepeny w he builds m imprnns thwasm.and wins does such wark himself orthrough his
Owe employers,provided that such Impro creenuam notinteMW aroffered for Wa If.
howenr,dee building or imp,onmen,is sold within can year of eompletion,the many-
builder will loan du burden of proving the,the did trot build or Improv for purpose or _
t1).
1,u ones of the gvpcnY•am exclusively cnueminl with licensed ronuwmn m
rombuct do p (See.7044.Brsinw• frsdam Code:)The Cnumuses u.
M Law n apply m an owner pent who builds or improves thereon,Md.
n
what =for s hpn e' wl cnumwnO licamed punuantmthe Canuwmrs
Lice law.
❑ m ,B&PCfmthi.. -
Owrcr Dam O �6
'S COMPENSATION DECLARATION .
the oder pc byofperboyeaeafdefolbwinl deelaratlon:
❑Ibveond willmatnuinaCmifirsuofComentmself-WureforWorkeraCampen-
sadon,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issud.
❑1 have and will mainuist Workees Compensation Insurance,as required by Section
3700af the labor Code,for dm performance of the work for which this permit Is heard.
My Workers Compensation Insurance orrice and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thmucdmn I ompleted 9 the permit lsforom humboddollars(1100)
ver ins.)
I anify then In a eXcea c work to AiNMh-pmniy" mound.I Mall not
employ any n((y mean mewbjecuotheforImmCmpemedon
Laws of Catlrurala. Lm
APPlicant
NOTICETO AP ICA ter making this CeniOcam f Exemptin.you should
beeome see the Worker's orepeuation provision of site Labor Code.you meat
Of0Mwl,h romply th wch minor or this permit shall W deemed revoked.
ti CONSTRUCTION LENDING AGENCY
[ti Ihereby affirm that them Iaa construction lending agemy,for the performance of
LY.> the work for which%io permit b laud(See 3097,Civ.C.)
QLO dors Name
a z Lender's Addmu
U0 I certify Nn 1 have mad this application and sum that the ebon Information is
(L.^'. coram.I agree m comply with all city and county ordinances and rote laws rtlating in
0 SV^ buildingenmumion,and he authwin reprounuti4c;of this city to enter upon the
W
WW=
rimpeetinpurpmea
demnify and keep harmless 0e City of Cupertino against
y d ezpenrs which may In my my amu against said City
ng of thispcook.DSAND WILL COMPLY WITH A L NON INT Issued by:qjtQ�&o Date
Re-roofs
Sign um afA numor ate
ARDOUS MATERIALS DISCLOSURE Type of Roof
plieam or future building oceapamnore or handle husrdous mamriat
as defined by the Cupenlm Municipal Code.Chapter 9.13,and the Hcalm and Safety
Cana,secdan 25732(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yrs ®K
Will the applicant or furore building occupant we eyulpment or dcvic s which If a roof is installed without first obtaining an inspection,I agree to remove
emb.hnardnus it...mala..M as dnared by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yrs �Nu
I have mW the hmardom materialrequirements underCTopter 6.95of the Celifor.
nu HcalNs4 Safety C 'au 3and2133d.I undersand dmifde Wilding
Jars mr(ttfe unentl an,.the y rtspanlMlitY to notify the occupant of the
myulre n prwissuanttahCcnifwteaf p r. SignatureofApplicant Date
3
0wWar All roof coverings to be Class"B"or better
e maria Dom