06030146 CITY OF CUPERTINO a,, '':>m "' d;.�,•
BUILDING DIVISION PERNIITCdS1vTRACTO'L2 T1�FOIYMATfIf¢�N ��
BUILDING ADDRESS: PERMIT No.0 6 03 014 6
10791 JOHNSON AVE
OWNER'S NAME: PERNOT ISSUE DATE
JOHN PAEK
E: SANITARY NO. CONTROL NO.
ARCHMC 1ENGINEER: BUILDING PERMIT INFO
BLODO EQ PLUMB MO
oi] LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby of es that 1 am licensed under proWiau of Chapter 9(commencing
,? iwith n fullction cean0Affeec DivWon3wfdanBusitwv WPro(catlwuCode,Wmylicenxat t. SFDWL-1 STORY 1, 895/GARAGE 4421
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Dau Dam Clara Lie,g
Cmmactor
qq
ARCHITECTS
oci DECLARATION
i 2 I unde.tanJ my plena Nall dein uxd As public rtcortu
lwU
r G Licensed Professional
py OWNER-BUILDER mDECLARATION
10 0 1 hereby.(firm on I am exempt from the Cssions o License C Law far tits
O o following won.(Section 71131.5,Bashers and Psst,dee ns Code:Any city or county
1$Pi which requires•e,also 1.o cdon,Me her.improv,de Permit
i or repair any stmcwre $431151
•Zi priorWiuiensedpM rc W can Me applicant for suehpermittolllwuLaw(Chkmcm
—�
that he is licensed PurauantWthe Provisions of the CmuacWr's lJcetsx law(ChaPut9 Sq.FI,Floor Area Valuation
(commcn,int,with Sccdm 700()of Division 3 of the Business and Prafousou,cook)or
— that he at exempt therefrom and Use bub for the alleged esempdm.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant W a civil Penalty Of 3 ALP14 WF67er= Occupancy Type
no,mart man Jr.hundred della.(SSW).
❑1,as,own,)of Bb property,or my=ploy=with wages As duo role mmpmea don,
will do thework,and the me..Isrolinunded oroRcred forsale(Sm.7014,Business Required Inspections
and Profevians code:The Conuxur's License Law dawn rot apply W wner an Oof q p
propenywho builds c rimprows Ibemoe,and who doesaueh work MmselforWmug),his
own employees,provided that such Improvements arc not tnunded oroRered for lata.IL
however,tha building or Improwment is sold within one year of cwmplwdon.the owner-
builder will haw me burden of proving that he did not build or improw for purpose of
ta^'lc.).
U/1.as owner of the property.am exclusively contracting with licensed conal..W
con.host the projett(Sec.70x4.Business and ProfeulOns Code:)The Cmuains's Li.
cenx law does not apply W an owner of property who builds or improws themen,and.
who contracts fat such projects with a cont.aoga)licensed percent cut the Contractor
License law.
❑i un eaempt under S B&P C fm that won
Owner Dau
ORKER OMPE S ON DECLARATION
1 hereby&aow under penalty of perjury nn,of the following tleclatations:
1 haw and will maintain a COCUResW Of Conserv to self-Insum for WorFerComPen-
aetion.As provldetl far by Section 3700 of the labor Code,for the per----of me
work for which this permit is issued.
❑1 haw and will maintain Worke's Comperemdon Insurance,as required by Section
3700 of the Labor Cada.fm Chun performance of the work for which this pe.1,b issued.
My Worker'.Compeuatma Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMFnON FROM WORKERS'
COMPENSATION INSURANCE "
(Teat swum need mtbecanpkud if Chan permit is for me hundredd m(51W)
Or lcsa)
I certify mot in the performance of me work for which this Pnmh is Issued.1 shall not
employ any person in any man W W cmc bran W me Workers Compensation /
Lam of California,Dau 4
Appllcanl r f
NOTICE TO APPLICANT:If.after making this Ccnilicau of Exemption,you should
become subject 10 the Worker's Compensation previsions Of the Labor Code,you must
Oforthwith comply with such pmvisions or this Permit shall be deemed mwkcd.
CONSTRUCTION LENDING AGENCY
[•-i Iherehy.M.then Vert is a construction lending agency far du perfurmmen of
ai> the work for which this permit Is issued(Sec.3097.Civ.C.)
W~n. Undoes Name
z tenders Address,
U 0 1 Certify that I haw mad this application ad sum that the above information is
U.f' con¢t.1 agree W comply with all city and county ordinance and sou taws totaling W
OU building convection,and hereby monitor rtPwntatiwa of this city to enmr upn the
oned
purpows
W ehavomcnudgm Property(and expenses whichm.
F FL (Win)agree to taw,indemnify and keep harmless the City of Cupenmo against
l'A Ii coisequeneof uecasuand expenses which may in any my accrue against said City
(„)'j, A consequence of the RSTA a of mat pemll. �J�_ 2
APPLICANT UNDERSTANDS AND WILL C MPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATIO�•'S. d
S Fa96k.-3a 69 /-'S.rrra Re-roofs
SigneiWcorAppl' mummer Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applirnter future building meupantmum or handle ha'rardons material
u de0md by dw Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section 25532(.). All roofs shall be inspected prior to any roofing material being installed.
Dyes I7No
Will thin applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hueednus air contaminsnu in defined by the Bay Arta Air Quality Management all new materials for inspection.
District[
❑Yea ¢lou
1 haw mad the Wardnus peau ialsmquircmcnu under Chapter 6.95 ofthe Glifor.
rile Health a Safety Code,Sections 25505,25533 am125534.1 oulcmand that ifine building
dma not currently haw a mmnL that It 4 my responsibility he notify Ilan occupant of the
requimmenuwhkhm`�M,.,"'�lpioorW�sum�c CCrURrWafaeupaney Signature of Applicant Date
"6 N`��"� All roof coverings to be Class"B"or better
Ownerorauthariecd m - Dau-