06070207 CITY OF CUPERTINO nr *+k •e q,,; . d .::z r 'i
BUILDING DIVISION PERMIT CONTRAGTQR INFQRNIA�I 9 Vr�
BUILDING ADDRESS: LUCY KO PERMIT NO.06070207
1585 JAMES TOWN DR
.R'S NAME:
OfPERMIT ISSUE DATE
LUCY KO
r- PHONE: SANITARY N0. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0e LICENSED CONTRACTOR'S DECLARATION Job Description
0 I hems,affirm that 1 are licensed under Pmvisons of Chap-9(mmneneing
with Section 70M)al'Divialon 3ofNC Business and Profession,Coan,and my license is
mfull fame and nrt 7So7� REMODEL MASTER SUITE AND ONE BATHROOM
LiceneeCluaaA_C 1pauer ti / �N ✓ , MINOR STRUCTURAL
ARCHITE�Iq-p
Do.�X �T-/ �G�F _CTs DECLARATION
i¢7W< 1 understood my plans Nell Inc need as Public records
In
Licensed Professional
OWNER-BUILDER DECLARATION
0 S I penalty.(Tum that 11. exempt from Nc Coheres Ca License Law for the
OO followingmassa.(Satin,1031.5,Bonuses and Pmfeadum Cade:My city ormmum
12 which us issuance.
a Permit m emmte epee improve,demmW,ri repair any comned toommore
-i SO thatki tsisuad psommhard.Wth,Neapionso far suchector'it micense rile a Law(Chumdnt ValU�rgag 000
Sxx< Nmhcslkmtscd Purmam tOthe provisions of Ne Comr4er'Wcemelaw(Chapmr9 Sq.Ft.Floor Area
7~� thatMits(commencing pt doe clan sand the
Want
r of the al Business edexampl Profession Cada)of
„�..
that he s exempt IMm(rom and de basis far Ne alleged r..w,puan MY vislNon of
Section 7031.5 by any applicant for a Pump subjects the applkant he a civil Penalty of APN Number Occu ancy Type
not mom Nan five hundred dollen(SM. 36610096 . 0 0
0 I.u owner of Ne i miaeny,or my employc"with wage u theirsoleeamperwuon,
.111 do thework,md deawclure is notinunded or o@rod tarsals(Sea.7014,Bexinw Required Inspections
and professions Cade:The Conuaelor's License law does rot apply N an Owner of q P
propenywhobundsorimprovdu n.andwhododosrhworkhimselfrthmgb his
however.the
vlded thatmch improvements am etas ear ofo uoncrN fm Gale B, !/
builder.Ne building u Mpro proving
within One year of mp ole for the Owner-
saeder will have the burden of proving Nu he did vel build m Improve far purpose of
sink.).
❑1.as owur of Ban property am exclusively contracting with Bamed mnuuron In
construct Ne project(Bee 7044.Business and Pmtessiom Cade:)The COauaemr's Li-
come law does not apply an an owner or property who builds of improvex thmoun.and,
who comacu for such prejeN with a eonuutods)licensed pursuant an Ne Convector's
License Law.
❑I am exempt under Sec. ,B&P C for this mason
Data
WORKERS COMPENSATION DECLARATION
<, I hereby affirm under penalty of perjury one of the followingdttlamllons:
0 1 haveand will maintain aCeNOcaa of C-menticaulf-louse for Worker"Compen-
sation,u Provided for by Section 3700 of de labr,Code,for the performance of the
woh far which this erm
pit uas
led.
0 I have Chad will maintain Workeh Compensation Inmranm,u required by Section
3700 of the labor Code,for one performance of the wank for which this Feral,is Issued.
My Worker's Compensation�IInnssurance carrier and Policy number sm:
tinier, S'T/r7e 7L/'bf� Policy No.: 10 0
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This Wa loo head act be compleed if t e permit is foram hundred dollam(SIM) e
or leu.)
1 cutffy Nat in the random use of the work for which this pennh or Wood.l shall oat
employ any person in my mmmrm as b haome subject in the Workma'Compensation
Laws of California.Date
APPlicam
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation prevision of ue Labor Cade you mum
0 Z forthwith comply with such provision or N4 permit shall he deemed mvvked.
Z O CONSTRUCTION LENDING AGENCY .
[r I hereby alarm Wt there is a construction lending agency for the Performance of
C4> thO work fur which this permit is issued(Sao.3097,Civ.C.)
QLender's Name
z I mI es Address
U0 I certify,that I have read this application and sum that the above inroroutiun is
n. P comet.I agree to comply with all city and county ordinances and sure caws misting to
0U Wilding eoomoction,and hereby authorim represcmmives nrthia city 10 cnmr uPnn the
R7 above-mentioned property for inspection purPosos.
(We)agree o ave,indemnify and kap harmless the City ar Cupenino.gaint
sEi y liabilities,judgmens,coss and experun which may in my my acrnm against said City
in comequmce of the gnnuns of dais Permit. y i 7 �9
^•� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date ��/�
SOURCERECULgTIONS.
Re-roofs
Signature ofApplicamo Conuactnr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building rcupanssrorc or handle bar4rdous material
derincd by the Cu -me
Municipal Code,Chapter 9.12.and the Health and Safety
,Sedan us3z(ar All roofs shall be inspected prior to any roofing material being installed.
❑Yee No
Will that applicant r future building oceupmt use equipment or dcviw which If a roof IS installed without first obtaining an inspection,I agree to remove
..rep hraNme,air contaminants u dcOneL by one Bay Arca Air Quality Management all new materials for inspection.
District? yy ''
0 Yen ono
a
Ihavemal the hnardsesm=dalamquimnemsunder Chaper&95ofth Uifor-
nia Haled&Safety Cadc,Smiths 25505,25533 and M34.1 uedemand Naif ata Wilding
Jae.not cu�ntiy haw•anent.Nat it s my rrpanihility m no0fy Nd aeupant nr Ne
rcquircmcntw mum hamipriormismmmof.CeNnamofGccup�;y. Signature of Applicant Date
v g f ' All roof coverings to be Class"B"or better
Owner an amborimd agent Das