06040106 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ;Cort'x' . " ? T ; `b.,,,iTTOr>, �
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BUILDING ADDRESS: JAE W PARK PERMIT NU.06040106
10210 JOHNSON AVE
OWNER'S NAME: PERMIT L4UE DATE
JAE W PARK SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG
17-7o I�ELECTIL!?
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PB MECH
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�00 LICENSED CONTRACTOR'S DECLARATION Job Description
j I hereby affirm Jul1 am licensed under provisions of Chapter 9(commencing p
with Scene.70asp o'Dividan 3 of the Business and Prafcasiom Code,awl my license is
full fomeand eff.L ADDITION 1040 SQ FT/GARAGE 442 SQ FT
ow '
ChamLte.g
DSANITARY IS SUNNYVALE ' S JURISDICTION
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ARCHITECTS DECLARATION NEW OWNER JAE W PARK-9/21/06
y I understand my plana shall be used as public minima
)y
'aa� Licensed Professional
set OWNER-BUILDER f DECLARATION
651
1 hereby.mem the i 1. aeept from the Contrwmts License Law for me
p o following record.(Section 71131.3,Buatwaa and Profession Code:Any city or county
3$ which its Issuance.
a a permit re construct,alter improve,dcmdlLJt.or mash any ud mare
prior mitstssuawd.nsurcquircnhc previsions
forthe on actor's o rile a Liomese US.(Charter
Valuation
�c that he ulicensed pursuanuo the provisions o(thd Conuadm'sLkcnse Low(Chepmr9 Sq.Ft. Floor Area
5 I (commencing with Section 7000)of Division 3 of tae Business it Profmsiom Crile)ser $247863
RI
�., that he is exempt therefrom and the buil for the alleged exemption.Any viola0un of
Section 7031.5 by arty applicant for a permit Subjects the applicant in a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(5500).
O I,as owwr of the properly,or my employees with wages as their role compensation,
will dothewakindtheswcmreI,nauntandedoraffemdintake(see.7oa,Busines Required Inspections
and Proui
femu des.1 The Co.=Wes Lt..Taw dwt apply m an owner or q p
property who builds or improves thereon,and who does such work himself or through his
own employes,provided that such impewments arc notimemded dampened far sale If.
however,Ne building or Improvement is sold within oro year of completion.the dwne-
builder will have du burden of proving that ha did min build or improw for purpose of
talc.).
O 1.a Owner of the properly,am eaelmively contracting with licensed comrwmm m
construct the project(Sec.7044.Buemess and P flandons Code:)The Cr uacmr's LI.
cove law data nm apply he am owner of property who builds or improv demon,and.
who convects for much pmjedu with aconuammr(s)limned pursuant in the Conuacmh
License Law.
O I am exempt under Sea �"y.�r�� ,B&P C for Nis mason
Owner —A1t;)` . �ireu/�__,. _Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaradone:
I have and will maintain a Ceniftcnu of Consent no self-imam for Worker's Compen-
sstion,or provided for by Section 3700 of the Labe Code,for the performance of the
work for which this permit is issued.
O 1 have arrd will maintain Worker's Compensation Insurance,u sequimd by Section
3700.1'the Labor Code,fm me performance of the work fdrwhich this permit is Issued.
My Worker's Compensation Insurance artier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
MIS section wed native completed true,permit is portio hundred dollars($100)
or Ica)
I comfy Nat in the performance of the work fm which this permit is isswd,I shall not -
employ any poison in any manwrse as m become subject lathe Woeken'Compemadon
Laws of Califorma Dam ,
Appl)nnt
NOTICE TO APPLICANT:IL after making this Conundrum of Exemption,you should
become mhject m the Worker's Compensation provisions of me tabor Cade.you must
.J O fdrlhwith comply with such provisions a is permit shallm
be deemed revoked.
CONSTRUCTION LENDING AGENCY
(~ l hereby affirm WE them is a construction lending agenry,for the performance of
ai the work for which this permit Is issued(Sec.3097,Civ.C.)
W�Q Lender's Name '
z Lender's Address
U 0 I certify that I have read this application and rule that the above information is
W correct.I agree to comply with all city and county ordinances and stile laws miming e
C:)V building construction,and hereby aummim mprescnutiva of this city to enter upon the
Uabove-mentioned property for inepec0on purposes.
(We)agree to save,indemnify and keep homeless the City of Cupertino against
a�.t ,`r�A liabilities,judgments,costs and expenses which may to any way accrue against Said City
D^+
APPLICANTin UNDEof the RSTANDS Aof SND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
l a r/_-aL— 9�a/ Re-roofs
Signamm of ApplianpComrwmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fawn building Oecommusu rc orhandle haamdov material
as dented by the Cotentno Municipal Code.Chapter 9.12,and the Health and Safety
Cale.Seetidn 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
OYa ONO
Will the applicant ar future building Occupant use equipment or dcvles which If a roof is installed without first obtaining an inspection,I agree to remove
II hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea ON.
1 haw mad the hnardws mamrialsmquimmenu under Chapmr6.95 ofthe Celifoo
nia Halm&Safety Cade,Seedom 25505.25533 and 25534.1 understand thetpthe building
docs not currently haw a mmol.that it u my Malawi in wtil'y the acupant of the
requirements which must W met priormiuuw ora ceniRc.m dr Rau Signature of Applicant Date
--t� • c 7 � All roof coverings to be Class "B"or better
Owner or aumodred agent Date