04030045 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Cfl�i` .IACQRXP�T''`gtMtT. d1 + .
BUILDING ADDRESS: EMANCON INC PERMIT N004030045
.ii n74 T.A17T7\TA rr
PER'S NAME: PERMIT ISSUE DATE
jPAUL POON 1227 PE QS WAY
PHONE: SANITARY NO. CONTROL NO.
(408) 739-9581
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y o p LICENSED CONTRACTOR'S DECLARATION
1 hu mby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 7MB of Division 3 of the Business and Prefes5bl.Code,and my he...Is
infu0mrceandeffeet. VISI -IN HOUSE USE ONLY
j Z License Class Lie.at
Y` Dam ARCHITECT'S EDcuRATION NO NEW PERMIT ISSUED/ORIG. #03070130
ssLtars i understand my plans shall he uM as public mcor.
76
Licensed Professional
D
g 0.1 1 R...'exempt
from
DECLARATION
$ I hereby affirm Nm 1 em uusin from the Contractor's :Any c Lew for the
O O following mason.(Section 1 construct,
Business and ere.demolish.
Code:Any tiny or county
iz$ which requires a pexin re cnr sw0.alma improve,h Permit t ri e a sig any structure
Fry pdorm its issue=.pursuant
requires;the thovisio sof for Commuters
o mrmil torileLaw(Chapstateter
em
< (comma(commencing
wit pursuant tithe provisions of the Conuacmr and Professions
Codmr9 Sq,FL Floor Area ValuatiOM107
z G ftL he its exempt
Scnlon men dahand the
Division sar the
rbc elled exemption.
on.ca y vi lation or M
3� taut he is exempt iMmfrom and Ne buts fm Ne alleged caempfon.My violation of
Section 7031.5 by a"applicant for a permit subjects the applicant to a civil penalty. APN Number Occupancy e
not mom man five hundred dollen($500). 32608102T. 00
p y Typ
❑Las owner of the pmpeny,or my empioym wire wages u Meir sole compensation,
willdo the work,and theawclum is nolimended"offered formle(Sec.7044,Business Required Inspections
and Prophetic.Cock:The Commune,License Law dors not apply to an owner of q p
property who buiidsorimprows the con,endwho doessuchworkhimselforthrough his
sem employees,provided that such improvements are not intended ora@red forssle.IL
however,the building or improvement is sold within one year of eemph uon,the owner-
builder will have the burden of proving than he did not build or improve for purpose of
C]1.ea owner of the pmpemy,am exclusively contracting with licensed contractors to
uw
coct dm project(Sec.7044.Business and Professions Code:)The Contractor's Lt.
came came
law coca not apply to menu of property who belles or improves thereon,and
who contracts,for such projecis ta with aconuacm(a)licensed pursuant m the ConvamM1
o
License
nse LLew.
Iun exam funder Sep. .Bd:PCfor miaor rwon
AOL'r
WORKER'S MPENSATI NDE RATION
I hereby affirm under penury of perjury am:of the following declarations:
❑1 have and will maintain a Certificate ofComent to self-insure for WmkeraCompcn-
ntien,as provided for by Section 37011 of the tabor Code,for the perfmmana of the
work far which thin peril is issued.
❑1 haw and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the Performance or the work for which this permit is issued.
My WorkcYs Compensation lasurence ani.and Policy number am:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbsecmon need not becomplmed tribe Permit is fmow hundred dollars($10(B
or Mss.)
1 ceNfy\that in me performance or the warfor which Nis permit is issued.I shall not
employ enypcmptpinany mm so salt qme mbjcct to the Workcri Compemetlon
Law.,Laof CN�R! i-YUam
APPIi enl J
NOT( E APPLICANT:If,after making thin Cenifrcato of Exemption,you should
bac ubjen m the Worker's Compensation provisions of the tabor Code,you mum
.JO foMWi comply with such provisions orthis perminahall the deemed revoked,
"" CONSTRUCTION LENDING AGENCY
I hereby alfrm that ahem is a co.uuction lendingage.y for the perrurenmuf
LYi> the work for which ibis Permit is issued(Sec.3097.Civ.C.)
IL7 Q Lender's Name
=z Lender's Address
G Q I=try that I have mad this application and rum that the above information is
{L Pcond e 1 agree to comply with all city and county ordinermes and such,laws relating to
0 building convection,and hereby authodm mprmantaam or this city no enter upon the
W shove-mentioned property for inspection purposes.
IY (We)agree to arc,indemnify and keep harness the City of Cupenino against
,n liabilities,judgments.coats and expense,which may in any way acc=against mid City
U 7 in consequence of the granting of this permit. \
�i APPLIC NT UNDER NDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOU EGUL
' /r �r Re-roofs
of ApplicantlConaacter Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or funum building occupant more orhandle havamoua material
cklmod by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Sceft.rly. 6H.2ss3z(a)7
❑Yes All roofs shall be inspected prior to any roofing material being installed.
�
Will the applicant or future building occum use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnus air conmminann u defined by the Bay Arca Air Quality Management all new materials for inspection.
District'
❑Yes 0110
I have real the harardous materials roquiremcnts under Chapmr 6.95 of the Califor-
niaHcalth&S,afctyCcdc.Sec6o.8505.8533.d25534.1undcrsmndthaifnhc building
Jibs not cmrcml .how a tone. at it u my responaih by w n Yy the m:cupam of the
rcyuire h mum rier iemenannce.ficam aapan . Signature of Applicant Date
o amhmized agentc D,m U All roof coverings to be Class"B"or better