04080240 & ,CITY OF CUPERTINOi
�BOILDING DIVISION PERMIT CONTRACTOR-INFQRMATI0N :z
BUILDING ADDRESS: CHRISTINA CHAO PERMITNO04080240
10800 J
OWNER'S NAME: PERMIT ISSUE DATE
CHRISTINA CHAD 10800 JOHNSON AVR ?nn4
E:
SANITARY NO. CONTROL NO.
ARCHITECTS GINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
u00 LICENSED COKIRACTOR'S DECLARATION Job Description
m I hereby AMma Out I am HamN under provisions of Chapter 9(commencing P
=u, wit Section 7wMo(Division 3 ofdte BuMMM and Profusions Code.and my license is
I.full fameanJAffect. ADD 490 SQ. FT. (2ND-UNIT/KITCHEN, LIVING. BEDRO
j vq z Liccnm Claes l.ic.1f
t;- Dam Comment'
public
ARCHITECT S DECLARATION
y3 1 1 understand my plans shall be used u puhlic mcnrds
A
C Licensed Professional /
g OWNER-BUILDER DECLARATION /
<P I hereby affirm Nat 1 am exempt from to Cmuractor'a License law for tK /
00 follnwing reason(Section 7031.5.Business and Pmnioo
fes Code:Any city or county �y
K m which requires a permit to cnnatmel,alma impmve,demolish.or mpair any nmetum Vnn
prior to its issuance.able requires the applicant for such permit to rile a signed summcnt - -
< tat he isBawed pursuant to no,provisions of the Cortraemrf Liana Law(Chapter 9 Sq.Ft. Floor Area alua[ion
YH$ (commencing wit Section Ng)O)of Division 3 of the Business and Professions Code)or
y _ tet he as exempt tcrefrom and tc besis far to snOid exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects Our,applicanuo a civil penalty of &II baze100 - Occupancy Type
not mom tan five hundred dollars(5500).
0 1,As owner of the property,or my employees wit wages as their sole compen ation,
will do to work and to aw.urt is not intended or offered tarsale iSce.7014,Busnm Required Inspections
--- -
and Professions Code:The Contracmfs Liavn$e Law docs not apply to an owner of q p
property who bonds or improves teman.and who does such work himself Or through his
own employers,provided tat such improvemama art at intended ars offered for We.If. '
however,to building or improvement is sold within one year of completion,to owner.
builder will have to burden of proving tat he did not Wild or improve fur p.T.of
sale.).
tI,es Owner of One property am exclusively contracting win licensed contractor to -
onsinner no,project(Sec.7044,Business and Professions Code:)The ConUrttrs Li.
cense Law does not apply,o an owner of property who builds or improve Lemon,and
who contracts for such projects wit aconuacmr(s)licensed pursuant M to Contractora
License law.
❑lam exempt..it.See. /gyp ,B&P C for tis..an
Ow er / 1 A f X-� De 0 7/0
WORKER'S COM SATIONDECLARATION
I hereby of ant under penalty of perjury ane of Om toll ' a.lantions:
M1Ave and will maintain a Certificate of Content to self-imeurc for Worker's Compen.
` More,As pmvided for by Section 3700 of Ore labor Code,for the peeformana of the
work for which tis permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,M required by Section
37W of to later Coat.for to performana of to work for which tis permit is issued.
My Worker's Compensation Insurance cavi.and Policy number are:
Carrier: Pal icy No.:
CERTIFICATE OF EX EM MON MOM WORKERS'
COMPENSATION INSURANCE
rills mesion sed not w comple ed if the permit is forone hundred dollars(SIM)
or len.)
I certify tar in to performance Of tw work for which tis permit is issued,1 shall not
employ any person in any manaorm as to become subject to the Workers'Compensation
Laws of Cahionno.Dat
Applicant
NOTICE TO APPLICANT.If,after making tis Certificate of Exemption.you should
become subject in to Worker's Comp.wdon previsions of the labor Cade,you most
,JZ fambMt comply wit such pmvilions or tis permit a hall w deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
F' I hereby aMrrm tat tort is a construction lending Agency no the per(ormana of
p'. dre work fur which this permit is issued(Sec.3097,CO,C.)
Lenders Name -
Z Lendeis Address
`
U Q 1 anify but 1 have read this application and sure that to above information is
D.P Correa 1 agree in comply with all city and county oNinames and state laws relining to
0U Wilding construction.and hereby autorim representatives of tis city to cater upon to
W above-mcntioncd pmpeny far inspection purposes
(We)agree to save,indemnify and keep harmless to City of Cupertino against
F' liabilities.judgments,ether and expenses which may in any way scene,against Mid City
U Z in consequence of to granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH fv NO -PO�riT Issued,by: Date
SOU VCO
CE CATIONS. IlV( (-1'
Re-roofs
ignat ofApplicaHAZAARDOUSMATERIAISDISCLOSURE ooMIor Date Type of Roof
Will to apPlirent or future building occupant stem or handle harutlous A.H.1
as defined by the Cupenim,Municipal Code.Chapter 9.12.and the Health and Safety
ode,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
C]Yes XNo
Will to applicant or future building Occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
it hvardws air conumimnts as dclined by to Bay Arta Air Quality Management all new materials for inspection.
DisVin?
Yet CYAu
1 have mal the bvardous materials requirements under Chapter 6.95 of to Calker.
nix Halt&Safely Curb,sections 25505,25533 and 25534.1 andprsmnd tat if ne wilding
does not currently have a¢rant Las it is in,.c pomihility an notify one oceupam of to
Lu nC9�w�"ma '�pa'O`tif ff°fAcc "'\f°la�fjlo Signature of Applicant Date
OwnorOraamOriv<aagentL 'o„e All roof coverings to be Class"B”or better