04080239 CITY OF CUPEIITINO A v°"o
BUILDING DIVISION PERMIT a CONTRACTOR INFORMATION
BUILDING ADDRESS: CHRISTINA CHAO PEKMITNO04080239
08
OWNER'S NAME: PERMIT ISSUE DATE
CHRISTINA CHAO jogion ._TQT4NqQN AVE 1.n10-7 /9
NE:
SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
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BLDGELECT PLUMB MECH
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u p LICENSED CONTRACTOR'S DECLARATION Job Description
0
m I hereby affirm Nal I am licensed under provisions of Chapter Y(commencing p
�iW with Sailors?IXIU)ofDivision]ofNC Businexard Profcssiom Code.and mylicersse is - - - - - - .
e>y in full force and effect' ADD 1003 SQ. FT. (LIV. /FAMILY ROOM/'MS BED/BATH)
i License Class Lic.g
r aFW
Dam.Contractor
' ARCHITECTS DECLARATION
5y 1 unMrstanla
d my pns shell W Used d public records
u.
`yU
O Licensed Professional
S OWNER-BUILDER DECLARATION
<I 1 hereby affirm Nal 1 am exempt from the Convenor's License Law for the
p 0 following mason.(Section?(D Lss S.Busineand profession,Code:Any eery nr county
K m which momma a Permit to cmmtncl,alter,improve,dumol'cah,or.,it any suuenrc
prior In its issuence.also mquims the applicant forsuch permit.Glc a signed statement
< thm la,is licensed .an,m the provisions of the Comraaors u¢nx Law(Chapter 9 Sq.Ft. Floor Area Va Uat100
sip (commencing with Section 7030)of Division 3 of NC Business and Professions Code)or
at
$ that he is eumpl therefrom and Use buns for the alleged compilers.Any violation of
Section 7031.5 by any applicant for a permit subjecu the applicant m a civil penalty of 'A`P$fA`Ii3�78er00 Occupancy Type
not mom than five hundred dollars($500).
0 1.u ownu of the pmpeny,or my employes with wages u Chir xk ampenudon,
will do the work,and the include is not intended in offered mosaic(See 7W.Businus -
and Professions ends:The Committers Liaise law docs ren appy to an owner or Required Inspe ipa�_
property who builds orimprovu thereon,and who diessuch work himself orthrough his
Own cmployeu,provided thmsuch improvemenu...I intended oroRcrcd far saln.IL
however.the building"improvement is sold within one year ofcompktlon.the ownco-
builder will have the hurden of proving Nat h.did And build or improve for purpose of
sale.).
L u moof of m pmp ,art am exclusively contracting with licensed smunic ons to '
nstron the pho-(Sec.1046,Buiness and ProfessionsCade:)Mat ConvacwlsLi-
<cnse law docs not apply Loan owner of property who Wilds or improves themon,and
.Law fm such pmjccu with aconuanerts7lianudpursuantm Ne Contfecmta
x ami.
cto.
I aim ext pl under See1.a ,B&P C far Nis reason
Ow ' I _ Wks^ Dale I J
WORKER'S COMPENS N— , N
1 hereby affirm under penalty of penury ore of a following deClaatiuns:
I have and will maintain a Centuries,of Consent to sel6insum for Worker'sCompen- - —
smion,u provided for by Section 37M of the labor Code,for the pelfarmana of the
work for which this p:rmil is issued.
I have add will maintain Worker's Compensation Ins,uman c,m reyuimd by Section
1]00 of the labor Cade,for the pciforn ads.of the work for which Nis permit is issued.
My Worker's Compensation Into...rani.,and Policy numher am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thir armors need not Mcompleted tithe permit is Toon hundred dollars($1000
or less.)
1 certify that in the perfennana of the work for which this permit is issued.I shall not
employ any person in any manner an as to kemme subject to tW Workeri Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:if.after making this Cemlicam of Exmpsion,YOU should
heceme subject to the Worker's Compensation provisions of the labor Code,you must
0 Z r."vilh comply with such provisions or Nis permit about W doomed nevaked.
Z O CONSTRUCTION LENDING AGENCY
EI hereby affirm deal there is a construction lending agency far the Performance of
7 the work for which N¢permit is issued(Sec.3091,Ci,C.)
If] Q Lender's Name
:D Lender's Address
VC) 1 artily too I have nail Nis application and sine the,the above inromuvun is ,
{I. Centel.I agree to comply with all city and county moraines and sou laws relating to
O U Wilding construction,and hereby authome repmxnutives of this city to enter upon the
ahove-mentioned property for inspection purpose&
H t1. (We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilidu,judgmenu.corta and,.,.which may in any way senor against said City
O? in APPLIC N'TUNDERSTANDScof the granting Of IAND WILL COMPLY WITH ALL NON.PO,{NT Issued by: Date �^
soug�FiREcuLgppNs. n� �G() r� Re-roofs
Siguadurc of ApplicanUConvactor are
�� HAZARDOUS MATERIALS DISCLOSURE Type of Roof
asvtll the applicant or future Wilding Occupant mre or handle harardous material
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Ai�kralc.Section 155J2(a)? e All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant or future building occupant use equipment ordeviaa whim If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conmminanu as defined by the Bay Asa Air Quality Management all new materials for inspection.
Dewitt?
CYu No
I ban mail the haardous materials requirements undirrChaider 6.95 ofthe Califor,
his Hralub&Sallety
equire envunderChapter6.95oftheCalifor-
hisHralN&Salley Cede,sections 25505.]5533 and 25534.1 undersand deal if Nle Wilding
data not currently have a a um,that it is my mspomibility m notify the..part of the
mquimmtn It hpostWmetpriorI anaefaCrnihnteafOct Signa[ureofApplican[ Date
1 P � I°��I °a
a uth.riaedagenl Dat. All roof coverings[o be Class "B"or better