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CITY OF CUPERTINO^'r
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T„vNF,ORMA'ION• ,
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
ROBERT & JUDY WONG
PERMIT NO. 05080012
21174 LAUR DR
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HER'S NAME:
PERMIT ISSUE DATE
ROBERT & JUDY WONG
2005
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SANITARY NO. CONTROL NO,
ARCHIIEC IENGIbli
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby Arm that 1 am licensed under provisions of Chapter 9 (commencing
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withSectionDivision the BusinessBusinessAnd Profculons Code, and myliceMcis
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nfull fres Af
anAffect.
REMODEL KITCHEN & BATHROOM & ELECT
LiceDow. Class ue.g
Dam
ADD GAS LINE TO COOK TOP
ARCHITCfT3 DECLARATION
`rS DEC
1 understood my plana 'hall W used As public records
Licensed Profcutonal
OWNER -BUILDER DECLARATION
1 hereby affirm that I em exempt from the Conbamor's License Law for the
following reason. (Section 703 1.5, Business and Professions Cade: Any city or county
which requires a permit In construct, atter. Impmm. demolish, or repair my structure
prior to its issuance, also requires the applicant for such permit to file a signed comment
Ft. Floor Area
Valu 60000
than he is licensed pursuant m the prevision of the Contractors License law(Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of Ne Business and PmRAAm nCade)or
that he 4 exempt liberation, and the buts for the alleged exemption. Any violation of
N tuber
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
sat mare than Ow I mMred dollars (8500),
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3 2 6 5 20.00
❑ I. An owner orale property, or my employees with wage As their sole compensation,
e
Required Inspections
wilida thewark and theatructure 4notlnandedmoRered (orsale (Sm.70N,Budnm
and Pesfeumns Code: The Comrscmfa License Law coned, onot apply m an Owner of
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pmperty who builds or Improves Nueon, and who doss smh work himself ar Uuough his
awn employees, provided thumb Imprevemanu art nm am oraEerest forsala 11,
however. the building or orprovement Is sold within arc you of mmpleuon, the owner.
Wilder will haw da boAen of proving that he did Act build or improve for purpose of
1. As own, or the property, Am exclusively contracting with licensed mnuactas m
truth the pmjca (Sec. 7014. Business and Professions Cede:) The C'ontracto's Lb
cense law does not apply to an owner of property who Wilds or improves darter. and,
wW contracts for such pmjeeu wird •convuetodU licensed pursue, m the ContrsmYs
Lkenx law.
❑l am exempt under e. .BBPCfe Ws moon
Owner Daa D,
KER'S CO ENSATION DECLARATION
I hertby aft under penalty of perjury one of ata following declarmiou:
ham and will maintain a Cenl0esa of Consent to self-lasum scar Worker's Compen.
boson, as provided for by Section 3700 of the Labor Code. for the performance of the
work fm which this Permit is issued.
❑ 1 have And will maintain Worker's Compensation Insurance, a required by Section
3700 of the IAWf Code. for the perfarmuce of the work for which this permit is issued.
My Workee, Compensation Insurance carrier and Policy number art:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TL is sermon toed ant he completed tf tib Permit is for one hundred dollars (SIM)
or kse)
1 certify the, in use, performanm of ata work fa which N4 permit 4 issued. l shall net
employ Any pecan in any m era u gram subject m the Workers' Compensation
.
Laws of Califon, Dao
Applicant
NOTICE TO CANT: IL • er making This Certifies¢ of Exempdon, you should
bocome rob' m the Wo lan'a CompensW on provitions of the LAW Code, you meet
foMwith comply with such prov4lmu or this Permit Nall W demand O voiced.
CONSTRUCTION LENDING AGENCY
I herby Amm that Vert is a mnsunawn leading agency for use Performance of
the work fur which this permit 4 Waned (Sec. 3097, Civ. C.)
Undoes Name
Lenders Address
I cendfy that I have rtW ft. Application and sum that On, above inform Wan is
comwL I a&= to comply with all city and county ordinances and sate lawn reluing to
building construction, and hereby authollm represematiws of this city to encs upon tha
&hove -mentioned propeny for Inspection purposes
(We) agree to save, indemnify and keep hsrmleas the City of Cupertino against
Iiablli0ns, judgmcats, core end expenses which may In any way mere= against cold City
in consequence of the gaming or this permit.
APPLICANT UNDEASTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULA NS, / /
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Re -roofs
Type of Roof
Signature of Ap i .Con r Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant or factum building aecupantno n orhandle hauNous material
AsId.defined by me Cupertino Municipal Code, Chapter 9.17, and the Health and Safety
Me. Section u531(a)7 I�,
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ®Nu
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment u devices which
hammers air conuminanu u defined by the Bay Arca Air Quality Management
all new materials for inspection.
ict7
❑Yes No
I ban mad the hu ons rials requirements under Chsper6.95 ofua CAlifor.
kalth&SatctYCade.SeNans73505.755JJ UW7553/.l underaaM thuif the Wilding
not curet hew a avant that It 4 my responsibility m natrfy the =Van, of tise
rements nmtretWme,priarmiswaseeenCertifiesearOc pan
Signature of Applicant Date
All roof coverings to be Class "B” or better
owner ser at rima. ant Dam
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