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04040144 CITY OF CUPERTINO -- •= ^ BUILDING DIVISION PERMIT CONTRACTOR XNF6C MATIUTi.•., 6UILDING ADDRESS: PERMIT N10 4 040144 42n T,TNT).qAY All ER's NAME: PERMIT ISSUE DATE GHEE-KEONG Y ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 y0, LICENSED CONTRACTOR'S DECLARATION sss�� F1 hereby from that I am licensed under provision of Chapter 9(commencing Job Deseript�I�� wiNSecdon70XFof Division 3 of Ne Business and Professions Code,and my license is infull enefares Ciansnd effect. ADD 636 SQ. FT. (MS SUITE) LED S License,Clan Lk.N �� Dem Cun v� ARC HITECTS co(understand my pins shallmlurecrs OCT 74 2 004 �yU ;o Licensed hereby affirm BUILDING OWNER-BUILDER DECLARATION I hereby affirm thin 1 1. exempt from the Contras Co License Law for the, 00 whichfollowing maSa a.permit 7lDLS,Baalteraand mprve.demolish, to Asy Clly of Conry which requires a permit ser construct,eltec impmvc,demolish,or repair any svucmrc mi� prior m its issuance,alas requires the applicant for such Permit to Ole a signed statement Nat he is licensed pursuant o the provisions of the Comments's License Law(Chapter 9 Sq.Ft.Floor Area Valuation $ (commencing with Section 71100)of Division 3 of NC Business and Prafcssina Code)or ,�.. that he u esampt therefrom and the basis for the alleged exemption.Any violadon of Section 7031.5 by any applicant for a permit subjects the applicant an a civil penalty of 3"N2Ql3Jtl8erO0 Occupancy e nor more Nn fives hundred dollen(5500). P Y EYP 1,uownerof0epmpeny,ormyemployeuwimwagesudmirmlecompenudon, willdo the work,and thestructuse isnot intended oraffered foraale(Sec.7064.Business and Professions Code:The Contrecmre License Law does not apply to an owner of Required Inspections pommy who builds orimporms thercon.and who does such work himselfor through his own employees,provided thatio ch imprommn0 art nor intended orofferead torula If. however,the building or improvement is old within one year of eompledon.the owner. builder will haw:the burden of proving that be did not build or improve,for purpose of pre.). 1,as owner of the property,am exclusively contracting with Foamed cantmnma to &,met the project(Sec,7W.Business and Professions Cade:)The Contruter's Li- cove law dots not apply Ir an..at of property who Wilda or improves thereon,and who contracts for such projects with a camnctar(q licensed pursuant to the Comme or's License Law. ❑l am exempt nder�SSry .B k P Ci�far this recon /�/1X�rit/u Gda.OJ-716170[4 0 ER'S COMPENSATION DECLAR 1 hereby affirm under penalty of perjury one of dte fes lowing dulmtiou: 1 have and will maintain aCeNficam of Consent m self-insure for Worker's Compton. action,u provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issueQ ❑I have and will maintain Worker's Compensation Insurance,u required by Section 3700 of the,Labor Code,far the performance of the work(Of which this permit is Issued. My Worker's Compensation Innnnce,carrier and Policy number am: Carder: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu section need not hecompleted if the permit is future hundred dollars($100) or less) I certify that in the performance of the,work for which this permit is issued,l shall not employ any person in any manner n u m become subject to the Workers'Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making dais Certificate of Eacmptiun,you should - become subject to the Worker's Compensation provisions of the labor Code,you must ,Jz forthwith comply with such provisions or this permit shall W deemed mvokcd. z'O CONSTRUCTION LENDING AGENCY [r 4 l hereby oRom that Hera is a construction Imiling agency Car the,performance of ai> the work for which this permit is issued(Sec.3097,Cih,C.) Dd Q Lender's Name z LandefAEdross I U Q unify that I have testi this city and county and sum Nat the above information is - 0 correct.l agree to comply with all city and county ntdiunces and sack laws relating e pU buildingconstruction.iomnd hesebyauthan puMmsenmtivu of this city to enter upon dte >i shove-(We) progeny findemniffins,socyan keep he (We,)agree to cove,indemnify and keep harmless the City of Cupertino against Z incomeajaceofhecostsndof this expenses which may in any way eccme against mid City i U,��[ in consequence of the graining of permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE RES,.� � J , t/lf llA/V4r '01010V Re-roofs si m ofAppliwnVContrut rDam HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII ma appiicnt or future building occupant atom or handl.hareafdous ni mrial defined by the Cupenina Municipal Code.Chapror 9.12,and the Health and Safety e. No se❑ es ctlon 25532(4)7 (L�a All roofs shall be inspected prior to any roofing material being installed. Ylf3 Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit hauNous air contaminants as defined by me Bay Area Air Quality Managcmern all new materials for inspection. Districl7 `�' C3 Yes 'IPrdu I have read the huarmurs materials rcyuimments under Chapter 6,95 ofthe Califor- meHenith&SafciyCade,Sections 25505,25533 and 25534.1 uMemnd mu if the,building dos not curtcnrly�ha a tenenL Nat it is my responsibility iliti m notify the occupant of the, i rcquim ts'Whidf�slspymetpriorwissuanccofeCcrdficateo(Occupancy. „v/G Signature of Applicant Dale / '/v�/YK�/ lf�`V�A_(A�1/ � �f All roof coverings to be Class 'B" or better Owner or ambanzed agent Ditc