06090055 CITY OF CUPERTINO ( ' R.. 4.
`
C10 �9UILDING DIVISION PET
�Ae
BUILDING ADDRESS: CHEN' S CONSTRUCTION CO "E"A""NO06090055
10190 LOCKWc)on DR
R'S NAME: PERMIT ISSUE DATE
WANG CHUAN 1271 WASHINGTON AVE, PMR 6 A ng/log/gong
PHONE: SANITARY NO. CONTROL NO.
(408) 655-9488
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�op LICENSED CONTRACTOR'S DECLARATION Job Description
b 1 hereby afrom that 1 am licensed under provisions of Chapter 9(commencing P
IM Section 70DW of Division 3 ofNc Business ad Pm(essinat Code,and my license is
in fullrarce and off REMODEL HALLWAY, BATHROOM REPLACE SLIDING AND P
i�_ LlcenM n Cte.d WINDOWS AND DOORS LIKE FOR LIKE
ARCHIF- Dam Co.D r
qq at.has he use DECLAR 1
i$ I derwnJ my pum+h+ll he used as public rmarM
)�l
ro Licensed Pmfcssional
OWNER-BUILDER DECORATION
I c c I holiday a(Sect that 11. eumpt from Pr Cosmos o :A n C Law for the
.sl o which re moon. ore don 7031.5,Business and ws.de run Cale:Any city err tory -
$ which requires a pemso re cares the alter.improv,h Permit
fl repair ed twcmm
:fey^ priorsiulssmme natlL thelheapplraalforConalmniuonenseLaWChap=9 statement VaIU$tpp®000
a (co times licensed pursuant m Mu provisions of Me Conwnessa LtecnM Ww(Chepmr9 Sq.Ft. Floor Area N+I/
9 that he
ing examp, Section 7000)d M buts
rM theeged exempt Proon.Any
Qrc)or
dial W u eampt Mumfrom and the bass for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit abjecu Me applrat to a rover penalty of APN Number Occupancy Type
net more Man Rw hundred dollars(5500). 34214042 . 00
-
❑1,a owner of Mie property,or my employs with wags as Meir ak compensation,
will do the work.and Me+huctum 1,Out intended arolhrtd for sea(Sec.7044,Bmineas Required Ins ecdons
and P ar,,dom Cock:The Contractors License Law dam rot apply m an owner or 9 P
property who bunds m i mpmws Meson.and who doea,a h work himMif or through his
own empluyces.provided Mel such imp..anemuartnotimendedaroffmedlerse,If.
however,Me Wilding m i est osanent u mid did
aro yes,ofi m Town fa.tle oww-
Wilder wiB have Me Wtdea of proving dol he did Out dim m improv far purpose of
au.)
.
❑1.As Owner of the property,am ass ue"ly cantranting with limned an0elom to
construct the project(Sec.7044,Business sed Profession Coda:)The Conmtmes l;-
case law dam not apply in an owner of teopeny who Wilds or improves Merton,ad.
who eOmraeu for ouch pmjens with a contractor(+)licensed p omm,in Ile Contranoe.
License I.
❑I as mempt under sec. ,B A P C for this mann
cr Dam
WORKER'S COMPENSATION DECLARATION
1 hereby eft.under penalty of perjury an Of Me following dmlanllan:
❑1haveandwnlmaintain•Cu6r%mwo(Comentmself-in+umfar Wo esCompen-
cation,as provided for by Second 37M of Ilse Latin,Code.for Me Incrimination of Me
work for which this permit is blued.
1 have ad will maintain Wmk ufs Compentem manna,as required by Seen=
3700of Me Laid Code,fm the pmfmmcce of the work fm which Mu permit u issued
My Worker'+Compassion Isumnce carver and Policy number am:
Camies�.-/w�O �-f/II�.rAc. Polity NO.:
ER FICA OF XEMMON PROM WORKERS'
COMPENSATION INSURANCE
(This Mellon need nal W completed if the p reeft is forone hundred dollars($100)
nr less.)
1 ccaify Mat In Me performance of the work for which this pure,Is Wood,l shall not
employ any person In any matter so as to become abject to the Workers'Campenation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IC eller making this Cenificee of Exemption.you should
become subject in Me WorkeYa Compensation provisions of Me labor Code.you muss
O O foMwiM comply who such paHsiom m this Permit the]he deemed awked.
z� CONSTRUCTION LENDING AGENCY
1hereby triitm Mm Mart is a eemuueann leading agmey for Me rafamerea Of
CC> Me work for which this perch is Wised(Sm.3097,Civ.C.)
WG Lenders Nanders me
is,= M LeAddress
U O I certify this 1 haw mad this applica ion and state Me Me allow information Is
is,P cancer.1 agree to comply with all city std county ordinances and sum laws relating to
OU building construction,and hereby authorire mprmenteives of this city to enmr upon the
� 0. ahow-mentioned property for inspection purposes.
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
rl'"y to liabilities.judgments,casts and expenses which may in any way scene against mid City
U Z in consequence of the grating of this permit.
�+ APPLICANT UNDERSTANDS AND WILL SqMPLY WITN LL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs C7
Signuurt of Appliwm am
HAZARDOUS
'Type of Roof
H US MATERIALS DISCLOSURE
Will Me applimntm lanae Wilding.Akmwpatcme m Weak handom material
dunned by Nc Cupeniro MUMsipal Code.CWpter 9.13,and Nc Hnithad Wety
le.may 25533(s)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ym No
Will Me applieat or rumor Wilding Occupant om equipment or darn,which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmardnm air mntaminass a defined by the Bay Area Air Quality Management all new materials for inspection.
Di
is `—
❑Ye. �'rN
I have mad Me haartl/o�uTs lmalcrials myuimmenu under Chop¢r6.93 of Me Califor-
4 OuMds Safety Cade,T..4 test it Is yrwor7553a.I un notify Me
Wiring e a
Jom not curmntiy haw s mnak Net it,my responihility It notify Me meupat of Mc
rcyulmmcnu which most be met Wuamu ofa Certife of Occp Signature of plica Date
Owner 01 autham agent Date 11 roof coverings to be Class nBn or better