03080042 CITY OF CUPERTINO
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BUILDING DIVISION PERMIT N CONTRACTORJNFORMATION .
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BU I LDING ADDRESS: �CUPERTINO CONSTRUCTION INC PERMITNO03080042
22279 JANICE AVE (LOT 1
OWNER'S NAME: 10079 SAICH WAY PERMIT ISSUE DATE
DANNY LEE 10/30/2003
NE: (408) 253-9000 SANITARY NO. CONTROL NO,
ARCHITECI'IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+O0 LICENSED CONTRACTOR'S DECLARATION O O O O
I u W I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�c. fullm Llmnsuorcomilrrufs'an
dro>. ���mcc is NEW 2-STORY S . F. DWELLING
=ro Dam ' Contractor (LIVING SPACE 3326 SQ. FT/GARAGE 664 SQ. FT. )
sE� ARCHITECTS RATION
F 1�a d m�wk� shall W I red public records
)yU \gar- \e aim---�'3
�O y Licensed Pnlfcaal...I
S OWNER-BU DER DECLARATION
I 1 hereby affirm Nal 1 am exempt from the Contractors License Low for the
00 fallowing mason.(Section?031.5.Business and Professions Corm:Any city or county
�m which requires a permit to construct,alte,improve,demolish,or repair any mnscmre
2i prior tons iastmace,lna requirea the applicant for such Permit to file a.vignedstatemenl
cs< Ibathe islicensW pursuanuothepmvssionnfine Contmemr's License law(Chmmr9 Sq.Ft. Floor Area Y3 t
It-� (commencing wish Section 7000)of Division 3 of the Business and Professions Coot)or
shat he is exempt therefrom and the beau for the alleged exemption.Any violmlon of
Section 7031,5 by any applicant for a p,rmit subjects Ne applicant to a civil penalty of Occupancy Type
not short dun firs hundred dollars(SSW).
0 I,as owner of the progeny,or my employe"with wages u their into compensation,
will do the work and the structure is not intended or offered for sale(Sec.7B14,Business
and Promsimou Code:The Contractor's Lt..law does or apply m as owner a! Required Inspections
progeny who builds or improves thereon,and who docs such work himself or through his
own employees,provided that such improvemenu are not intended or offered for salt.If.
however,the building or improvement is said within one year of completion.Ne owner. j
builder will have the burden of proving that be did Out Wild or improve for purpose of
"Ice).
❑1,as owner of de pmpcny,am exclusively contracting with licensed contractors to
eomwct be project(Sec.7041 Business and ProGasiam Ceder,The Conmctor's Li-
cense law does not apply to an owner of properly who Wilds or improves thereon,and __ I
who contracts for such projects with a contntIORS)licensed pursuant o the Contractors
License law.
1 am"emit undef Ste. .B&P L'far this realm
Owner Dau
WORKER'S COMPENSATION DECLARATION
40 1 hereby apEm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consenuo self-ituum for Worker's Compen-
Miian,as provided for by Section 37W of Ne labor Code.for the Performance of she
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,"tequimd by Section
37W of the labor Code.for the performance of the work for which this pored is issued.
My Work/e/' C mpcnsaion lnsvmnm ea 1 1my nunikf am: n
Cartier.V 7 oli,No.: �1'� h
CE IF�EXEMP ION FROM WORKERS'
COMPENSATIONINSURANCE
(Thu rection need not W completed if the permit is for one hundred dBars(SI W)
It..)
1 Unify thm in the perfl mance of the work for which Nis permit is issued,I shall not
employ any person in any manner sin as in become subject a the Workers'Comperwtion
laws
of California.Dat,
Applicant
NOTICE TO APPLICANT:If,after making this Cmificam of Eacmplian.you should
become subject to the Worker's Compouarian provisions of the la Wr Code,you mast
Z forthwith comply with such provisions or this perm it shall W deemed revoked.
L O
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is eomtruction lending agency for the performance of
:47 the work far which this permit is issued(Sec.3197,Civ.C.)
A Lender's Nam.
3. Lender's Admau
0 1 certify that 1 have read this application and sum that the above information is
y F-' comet.I agree to Comply with all city and county oNinances and sum laws relating to
�U building convection,and hereby amhorim represcnutim of this city to enter upon the
a hove mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Nliabilities.judgments,casts and exponents which may in any way accrue against id City
.-3 Z in consequence of the granting of this from it. (�
'--' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Dat /
SOURCER. E,GttLATIONS. 3 a_a�
Re-roofs
Si tore of Applicant/can or Date
HA DOUSMATERIALSDISCLOSURE Type of Roof
Will the applicant or future building occupant store at handle hvarduus material
as defined by the Cupertino Municipal,Code.chortler 9,12.and the Health and Safety
Code.Section 25532(a)? WrAll roofs shall be inspected prior to any roofing material being installed.
❑Yea WT
Will the applicant or future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
7.quircmmli
horardms air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection.
ct?
❑Yes
I haw mad the haraNmsmalenals aquiremcnts under Chapkrb.95 of the Califon
ca W @ SafegCork,Srcoo a 25505.25533 and 25534,1 undcrsund that if the Wilding
not cimendy have a Mount,main,s my respomihili to nntif tW occupant-run
whi usl W met Poollolssuance of a Ce m!M cupanry. Signature of Applicant Date
/b
cr or authorised agent Dam All roof coverings to be Class "B" or better