03020011 crrY or cuPEGONTRACTnR INFORMA "fir
BUILDING DIVISION
PFRMI�
BUILDING ADDRESS: HENRY LB PERMITN"03020011
10850 JOHNSON AVE_
W NER'S NAME' PERMIT ISSUE DATE
HENRY LO 11/04/2003
NL SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECN
100 LICENSED CONTRACTOR'S DECLARATION O O O O
EU I hereby affirm that I am licensed under Pmvisiom of Chapter 9(commencing Job Description
� with Section 70)lnaf Division 3 of Ne Business and Professinns Code,md my license is
in Bmrecanderteet. NEW 1-STORY SINGLE FAMILY DWELLING
i'q� License Class LIVING SPACE 2300 SQ. FT. /GARAGE 400 SQ. FT.
Data Contractor
ARCHITECTS DECLARATION
E � I undersand my plain shall M used as Public mwrtls
)yU
a C Licensed Pb fessional
Oe,I go OWNER-BUILDER fir DEthe Commences
�Q 0 ON
1 regim.(Sect thin I am,Burin from the Convenors License Law for he
S❑O which nt rias,..(Section]1131.4 Business and ane.d Professions Code:Any city or county
m which rtyuircs a Pcnnit m rnnnrucL alcor.improve.Jcmnliah,or repair any structure
iy prior to its issuance.also require the applicant rot such Permit o file a signed statement
22ma< That he is licensed pursuant to the pmvisiom of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Vap"000
zF� (commencing with Section 7000)of Division 3 of the B urines and Professions Civic)or
that he la exempt therefrom and he basis for Ne alleged exemption.Any violation of
Section 7031,5 by any applicant fon permit subjects the applicant to acivil penalty of 3Br Occupancy Type
not mors Nen Eve hundred dollars(5500). P Y YP
❑I,As owner of the pmrcrty,or my employee with wages As their aide compensation,
will do the..,it.and Ne structure is not intended or offered for sale(Sec.7044,Business
and Professions Cade:The Compactors License Law Jae,not apply to an owner of Required Inspections
property who build,or improves thereon.And who does such work himself ortheaugh his
own employers,provided that such improvements Are not intended oroffered for sale.if
however,the building or improvement is sold within one you ores, plan a.Neawmrf/ vdf t�
builder will have the burden of proving that he did not build or improve fur purpose r
..]a.).
AAA
❑I,as owner of the Sec.7 y,,B exclusively contracting with Licensed convamo to
construct heca not apply
in in Business and ProfusionsCodc)TheConvenor 'Li-
cave law docs not such
to an owner of pmpeny who builds or improves there !and,
who contracts for such projects with a conuacmr(q licensed pursuant to Lou, onto.
License
. L'rcenLicenseLew.
lame cm nJer .06 PCfor gig rtsson /
Pr
ee W N ECLAON
I hereby affirm under penal o(pe0ury one of the fallowing declarations:
Ihaw and will meinuina Ce ate ofConsem mxlfinaurt for Workeh ComPen- n
Saban,As provided for by Section 3700 of the Labor Code.for the perfmmance of the /
work for which this permit is issued.
I have sed will maintain Worker's Compensation Insurance,ss required by Sanson
3700 of the labor Code,for the performance of the work for which this pamnil is Issued.
My Workers Compensation Insumttce carrier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need nos M1e completed if the permit Is foronc hundred dollars(SIM)
or haus))
1 Lenity gal in the perfmmanca of the wink for which thin Pcrmi,is handed,l Ah.11 not
cmployany yy nymmncrsoasmheo mbjeclt ge orkeri Compensation
Law, li G.Litc
APPIIc
N TI r AC y lftfl making gig Ccnirc to of Exam Prion,you should
e subject to the o ter a Compensation previsions of he labor Code,you must
'0 Ih comply with lh provisions or this Permit ahold he deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency tot the Performance of
the work for which this permit Is isseed(Sec.309'1.Civ.C.)
ft1 A Lenders Name
z Lender's Address
U Q 1 cenify Lost I hale read his application and sum get the Above information is
U. F' comet.1 agree to comply with all city and county ordinances and state laws relating to
V building construction,and hereby euthorime mp=nutiws of this city to enter upon the
(1.1 ahm
ovoemioned property for inspection purposes
Loy (We)agree to neve,indemnify and keep harmless the City of Cupertino aCainst
Lar rA liabilitmajudgmenu,costs and expenses which may in any way aecme against said City
C.7 z in consequences the granting of this permit.
APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON INr Issued by: Date
SOU LATIONg.
Re-roofs
ignelurc of iaHCon LOOS MATERIALS DISCLOSURE Lot D e Type of Roof
Will he applicant utum building occupant store or handle havardous material
as dcEred by the Cotten..Municipal Code.Charar 9.L2.and the Health and Safety
Lade. r—IY. ON.ss3z(a)] All roofs shall be inspected prior to any roofing material being installed.
IQYe
Will he applicant or future building occupatn tax equipment or dcvi¢s which If a roof is installed without first obtaining an inspection,I agree to remove
II.Orgill air contaminants As defined by the Bay Area Air Quality Management
Digital? all new materials for inspection.
0Yes ON.
I have mW Loc huraNnusmauruls requirements under Chapter 6.95 of he Cal ifor.
ria Hcaldhh Sof 7Codc,SxdOM 255(15.25533 Aod 75534.1 undnsmnd huifhe building
Jas not cu y haw a anent,that it is my res,cool ility m notam ant of the
roquirem up most be t tar nissuanceoraCcnificauolOcc en Signature of Applicant Date
Owner atautbarned2 t E16A All roof coverings to be Class "B" or better