04100075 CI'['Y OFCUPERTINO tQit,It
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BUILDING DIVISION PERMIT' NCON7RACTORIINFORMATION.,
BUILDING ADDRESS: HENRY LO PERMIT Ng.4100075
0850 JOHNSON AVE
OWNER'S NAME: PERMIT ISSUE DATE
HENRY LO 10850 JOHNSON AVE 10/12/2004
NE: SANITARY NO, CONTROL NO,
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUME MF,CfI
L� 0
;o�p LIC ENS[DCOKnRis DECLARATION Job Description
;.5 1 hereby affirm that 1 am licensedd made,under pmxio
vins of Chair., mm
pter 9(aocncing p
<Z
y, with Section 7r"E of Division Sof the Busine.+sand Pacification.,enacand my license is
in tall eaaerreet. —STORY SFDWL
NEW 1
(2300 SQ. FT--LIV. SPACE)�„
qLicense Class Lie..
nFct Drc eunacLLtr GARAGE- -400 SQ. FT.
a As shall CTSDEChlicmcON ORIG. #03020011 EXPIRED/HALF OF THE PERMIT FEES
z< 1 undcmanJ my plant shall E used as public DECLARATION
JaU
3 a0 H
Licensed Professional
g OWNER-BUILDER DECLARATION
iaj a
V. 1 hereby reaso infirm ons I.S.exempt from the Contractor's o Licensee Law for the
p R following reason.Section 213 LBusiness and Pmfcainm Code:Any city or roomy
' which inquires a Permit so construct,alter,improve,dcmolixb,or repair any.aruclum
�z2
prior o its issuance.also requires the applicant for such permit to file a signed statement
Ymp that he is licensedimmorcnuotbeprovisionsoftheComracmr'',LicenseLaw(Chapter9 Sq. Ft. Floor Arca Valuation
se (commeelngwithsection-IlyglrlDivision3or)heBuslncssandProfesxmmCodc)or $313825
y;_ that he is exempt therefrom and Thr bit for the alleged exemption.Any vinlauon of
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
net more than five M1enared aaRars(s500). Pane Y YP
❑1,as owner ofthe property,or my employees with wages as their sale compensation,
ill Pr thework,and thestructureC antis intintendsoroffered for salepplytoan wrier or
37530823 . 06)
and any who
Cede:The improves
Ocourn. rid who Law docs not apply m an owner or Required
own
w era who builds i ed that suthereon,andwho acessuch wnhM1 roffredthough M11.
ownem,thebuildin provided said withiti arc n
intended or for owner.
builder[the building or den of prov in is cold within one year of improv for
the owrter
builder will have the burden of Proving Nm be citl not hui10 or improve fur purpose(if O
sale.). CT
Q 1.ai ower of the property,70,11amusine s and contracting with licensed Collimator
to
(a �hL a.00
cora,Law
theimpactnot (Sec.to an Business andrhowhoWsds or improves
Cs therson,Lid ___,{{{���___ `/ S
care contracts
curs not apply,e an owner or property who Wilds of improves Corson,and
who contracts for such prnjecu with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑lam ear to ntla See. .B&P C f nM1is rcazon ® R
o er D,uf8i�,'"�+c
O 'S P SATION Dr;CI )ti
I hereby sof firm u r Penalty of perjury oe of the following declarations:
I have and wil l renin inaCenifieate of Cnnwnuo self-i mount or Worker's Compere
cion,m provided for by Scction 3]00 of the Labor Crdc,for the performance of the
wood,Tor which this peon,is issued.
❑1 have and will maintain Worker's Comns
pemation Insurance,as required by Section
37W of he labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance causer and Policy number am:
Carie: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
QDis section need not be completed if the permits Ionic hundred dull...(51W)
or lass)
1 Beni fy Cat in the performance of the work for which this permit is issued,1 shuli not
employ any pawn in any manner sen as In Mame sub)n-uo the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:if,after making this Cenificaut of Exemption,you should
become subject to the Worker's Compo random provisions of the Labor Code,you most
.J Z, forthwith comply with such rmorrtom or this permit shall the dcemcd revoked.
ZO CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a comtruaion lending agency fm the performance of
h: Cc work for which this pooh is Issued(Set.3097.Civ.C.)
i37 Q Leader'x Name
Zi Z Lender's Address .
U O 1 certify Cat 1 have read this application and state that the abuse information is
F-' correct.I agree to comply with all city and county ordinances and stale laws rattling to
(]U building construction.and hereby amhoriac representatives of this city to enter upon the
F Gabovcmemiunea propertyoat for inspection purposes.
(We)agree m save.indemnify and keep harmless the City or Cupertino against
to incaitics,judgmc the
and capcmpermitM1may in any way accrue against said City
U z in cnnwy cold of the gaming of this la%lmll. r
^ APPLC NT UNDERST NDS AND WILL COMPLY WIT ALL NON-POINT Issued by: Date J
S\R REGULATIO //
�✓ Re-roofs
Signa m 'Ap an on aur tic
f AZARDOUS MATERIALS DISCLOSURE Type Of Roof
.W101d a plican,urfuture building occupant store or handle hacallous material
as coined by infoinn Muniapal de.Chapter 9,12,and the Hcalth and Safety
Code.oy.zss32(an All roofs shall be inspected prior to any roofing material being installed.
Will the applicant fumrc builJr If a roof is installed without first obtaining an inspection, I agree to remove
pp upam saw eyuipmcm or devices which g
itit riaamnex ai,ronammams d ed by me nay urea Ait Quality Management all new materials for inspection.
tien
❑vex
1 have read the haaardnus materials requircmcn a under Chapter 6.95 of Oc Califor
nix Health S Safety Code,Sccaons 25505,25573 and 25534.1 understand that ifthc Wilding
Jt"c nut currently ase a tenant,that it is respomi th,ur nnaly the occupant of Ce
myuirc cnuwi must to inn prion - ane
enI.ccmrcateef Occupancy. Signature Of Applicant Dale
ownrr er actin t agent „e All roof coverings to be Class "B" or better �/