07110168 Y OF C
CTTUPERTINO
BUILDING PERMITDIVISION (RCONTI2A.G'��CCIR.INFURMA.TIO 'b
yx O
PERMITNO.
BUILTbFA5T"Js;OHNSON AVE TBD — TO BE DETERMINED 07110168
OW HELRt'SS SNALMEE; PERMIT ISSUE DATE
JIAYI LI 04/08/2008
PHONE: SANITARY NO CONTROL NO.
CHrTECrMNGINEER: BUILDING PERMIT INFO
9LDGO ELECT O PLUMB MECH
O O
Soo LICENSED CONTRACTOR'S DECLARATION Job Description
Ic,cby B.the,1 am licensed cede,pmvidoos of Chapter 9(Coromandel,
' withSeNon70M)ofDivision3ofcheBuchusandPro(cssiumCode,andmylicenseie DEMO 1 STORY SFDWL
^ y in full forte and effect
j Z License Class Lm.0
v, Dam Caouama, -
du
UCondescendARCHITECT'S DECLARATION
y1 Condescend my plans shall Me wu m
ed public cnNa
'a llccwed Pmlcssianvl
OWNER-BUILDER DECLARATION
.Z Q f I Mmby.(ue Nn 1 1. uempt from Ne Cssio moa,License Law for de
p O following uires a perrit t 7031.5.I.3,Buainer.and ad.dem ns Cadc:Any oily or county
structure$ which rots eau• d,also re corulruct aha,)mpmw,h renal t w repair any suwmm
primmim iensedprsuntto Me that applicant far suchnment'miccensM A eLaw(houl aamcnl
pps< awMisReeuta mnavm mW of Dieian,ofthe e B uhumr,LiccnsLame,Coca)or
Sq.Ft. Floor Area $7000 Valuation
rf g— that M Is comps attireection]and Man lWob f r of the Buai cauemmms and P,ofAn, Cede)or
Q that oc is e 13 b ary.p li and She basis far the U he a applicant
W Any vilacent or
Seedon]03136y a,ry appllanlforapemSil subjccu he applicant toarivll prnalty of
37518035 Number Occupancy Type '
nal mart Nan Bw hundred dollua(5300A
❑1,u owner of de propusy,m my rmploym withw{es u ateis sons mmpemdon,
ser R&ftwort,anddmswmamumlinandedoronemdm,aam(Sm.t0la.BuaiM•v Required Inspections
and Profesdons Code:TM conuacmr,License Law dm Out apply a an owner of 9 P
property who builds orimpow Wmeon,and who does,nch wort himselfw Waugh his
Can employees.Provided Wt such Improwmenu art nal intended oroEmed(or ad&If, '
however.Ne building w improvement is sold within am year of cempleuon.the namer-
builder will have the burden or purring that M did nal build or,improve fm purpose of
1,u awncr of the property.w udaaiwly contracting with limnmd cenuacmrt to
tract the protect(Sec.70th.Business am professional Cade:)The CoomcmYs Li.
corse Law dm not apply m an owner of property who Mild,or improvs thereon,and,
who conmea for such pmjec s what a eanlumm(s)licensed pwawm a ate Canuacnofs
Limns Law.
1]lameamnpt undm x BR PC for '
Owns Dam
(( ) OMel
RK COM ENSATION DECLARATION
1 nect, i 0 under Pendry of Perjury arc of the fallowing deelarad"":
I haveand will md.W.•Certifieau of cauenl a self-ituvm fvwartcrs Compery
rn,u provided As by Section 3700 of t e Labor Code,for ate pe,farmance of de
o
r,for which this Permit is issued. -
❑1 have and will maintain Worte(s Compensation I...as required by Section
37M niche Labor Conn.rte use performanc urban wart for which Nu permit is issued '
My WorMes Compensation Inter.carrier and Policy number ace:
(artier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Into sermon need natMcomplcued sate permit is fwanchundecd ddius(Slm)
or Coal
1 sonify dist in the performance of the wort for which this Permit is IsmN,I shill ani
employ any person in my mmner m-u�b evlbkn to Me Wmtmi Compensation .
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.Qf.after treating this Certificate of Ecempdon,you shouhl
become subject a the wonsces Compensation provisions of the Lahw Code,you muss
Qforthwith comply with such provisions sur Nis permit shall M deemed mvoted.
z�, CONSTRUCTION LENDINGAOENCY
[—r IMmbyalfrm this Nem iso com,wtlnn lending agency for the performawx of
ai> Ne wart for which this permit is issued(Sac.3097,Civ.C.)
W D Lender's Name
DZ Lamee.Add. .
U O 1 certify that 1 have mW this applicaum and sum this the above infarmatiun is
I,E correct.l agree m Comely with W city and County ordinance add team law,mlmal m
-0 building eonswcuon,add hereby uatodm rtpmsmuhm;of this city m caw upon che
WaMw-mem.ned prapeny fm iupecuan pugmsa
(Wc)agree to aver indemnify and trop ha,mleu the City of Cupertino against
y liabilitiu judgmcna,eruct and..ponce which may In any way acmue against to City
V Z In consequence of me grana.{of this permd.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITHI AL NON-POINT Issued by: Date
SOURCERE I.A770NS.
`rya PVfRe-roofs -/'—
Signal fAppli VCanDow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ate applicant or future building occupantstam arhandle handow mawrial
as dcOnad by the Cupertino Municipal Code.Chapter 9.I;and ft Health and Safely
Coac,Section 25532(1)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea Vin
Will the applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it bantams air conaminanta u defined by SM Bay Area Air Quality Management all new materials for inspection.
act? L/
❑Yea gNa
I have mad the huardowmataridsmquimmcnu under Chapmrd.95 of the Califon
nia Health k SdclyCodc,Sceumn25505,25533 am125534.1 undersand thsuifam Wilding
dm not contently have a mean,the,Il is my rupmuibilily a notify the occupant of ate
requirements wit' UILW met prior my}suancc of.Cenifcam or a76 Signature of Applicant Date
Owner or hori>ed ages Dow All roof coverings to be Class'W'or better.