05060097 CITY OF CUPERTINO c
BUILDING DIVISION PER1Vf.-i Cd)}.VTRACTC/R INFORM�ON
[n2e,I
ILDING ADDRESS: PERMIT NO.O 5 0 6 0 0 9 7
t nrxwnc)➢ DR
NER'S NAME: PERMIT ISSUE GATE
LYNN CHING is _
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
E00 LICENSED CONTRACTOR'S DECLARATION Job Description
O O O O
yUF I hereby$from that I am licensed under provisions of Chapmr 9(commenIcing p
`2a jy wirhSMian]IXsq of DivisionJof NC BusincxandP lessinn Co dc,andmybecnscis
<
in
fame fullerr12 Spa-13� DEMO (E) HOUSE
a�^o i Liceve Class' Lie a - ad �s t $
n Data Comuclor 00 !`NL LI T7 l0 T I�I I,� ) ' n f �j t FD
~Wj - ARCHITECTS DECLARATION U—� • u-��_ ` r �/ I �,J� < `t+rw _^LI
`t< 1 uOdcrsmnd my plans shall he used ic public records ) ��
SW;�� Licensed Pmfcuiantl 2005
i S OWNER BUILDER DECLARATION
a 2 1 hereby affirm that I am exempt from the Contractor's License Law fur the
00 following reason.(Seeuon]031.5,Business and Professions Cade:Any city or county 0pt Vitn 1y }}'
tom which requires a permit m construct,alter,improve,demolish,of repair any structure $N 8 G:� I �{%A qa�. Ts-8700 0
FZ„ priorto its issuance,also mquires the applicant for such permit to Glc a signed statement
asothat hot islicensed puaaanitothe previsions oftheContractor's License Law(Charmer 9 Sq. Ft. Floor Area ctr 1°�t='4J' "Valba[io`n'
yl- (cammencing with Section 70(t))of Division 3 of the Business and Professions Craft)or
ii Nat Ile u contentthereGom and the basis for the alleged exemption.Any violation of
SectiLn)831.5 by any applicant for a permit subjects the applicant o a civil penalty ofOGGoaraC
not mart man Gve hundred dollars($500). er 0 0 Occupancy Type
❑1,as owner of the property,or my employee with wages as their sale compensation,
will do the work,and hti swnure is not mudded or Offered for talc(Ser.7W.Business
and Professions Cade:The Contractor's License Law daca not apply in an owner of Required Inspections
Property who builds or improves thenar,and who does such work himself or through his
awn employees,provided thin such improvements are not intended or offered for sale.If,
however,me building or improvement is sold within one year of completion.the Owner-
builder will have 0th burden of proving But he did not build or improve for purpose of
sale.).
1,as owner of the"."I,ma exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense Law does not apply in an owner of infelicity who builds or improve duration,and
who contracts far such projects with a eontmctir(s)licensed pursuant to the Coo uacmer .
License law.
❑I sm exempt antler Sec. ,B&P C for this reason
cr Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
137W
have and will minimum a CeniOeate of Cement to self-insumfor Workers COmpcn-
n,as provided for by Section 3]00 of the labor Code,for me performance of the
for which this Permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Cade,for the performance Of due work for which this Permit is issued
Workers Cq)teasa}iopr�/ rintt Cootie and Policy�nuam�b�er�a¢:((,Q.�cr:� � T U y�Policy Nm:t6"_-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This auction need not be completed iDhe permit is for one hundred dollars a1 W)
less.)
I cenify mat in he performance of me work for which this Permit B heard.I shall not
employ any person in any manner sit az to become subject to the Workers'Compensation
Laws of Califamia.Date
Applicant
NOTICE TO APPLICANT:It,ager making this Comflearc of Exem Plan.you should
became subject to the Worker's Compensation provisions of the labor Code,you must
.J O forthwith comply with such provisions or this Permit be deemed revoked.
'z17 CONSTRUCTION LENDING AGENCY
(-� I hereby affirm that mere is a construction lending agency for the performance of
<Ythe work for which this permit 0 issued(See.3097,Civ,C.)
Q7 F I<ndra's Name
az Lenders Address
U 0 1 cenify mat 1 have¢ad his application and sum thm me above information is
B, F torten.1 agree to comply with all city and county ordinances and sure laws relating to
0U building construction,and hereby amhmise representatives of his city to enter upon the
F Gahove.menuancd property for inspection whiposcs.
(We)agree m save.indemnify and keep harmless the City of Cupertino against
N
liabilities,judgmentsecostsand ethic Permit. may in any way accrtw against said City
V z inconsequence UNDERSTANDS
this permit.
^� APPI.IC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC REGULATIONS.� Gl—f r� Q I1 I d J
Re-roofs
a StgnaMrtpplicaHAZARDO - ale
HAZARDOUS MATERIALSd O LOSURE Type of Roof
Will heapplicantm(Mune buildingk.Chainscorenradd da ha'r.1th $material
defined by the Cupertino Municipal Cook.Chapter 9.12,add he Hcalh anJ Safety
.Second 15532 r)1 All roofs shall be inspected prior to an roofing material beim
❑Yet �n , P P Y g g installed.
Will rhe a r licmt or future building anti equipment If a roof is installed without first obtaining an inspection,I arree to remove
J ' I P b pant use a ui r or devices which a
J d h.,unions air contaminants as defined by the Bay Area Air Quality Management ill new materials for inspection.
Dimrau?
YesNu
I have maJ due herandnus nmmrials requirements under Chapter 6.95 of the Cali for
ria He N&Barry Cade,Secuoru E55(I5. SJJ anJ 25574.1 undersand mulrthe building
docs n tcunently M1ave a mnanh thm it my msponsihility m nouly tM atop t of he
d.Oi en, !i,Catt�annp n,ttrananracen;Beanoul me
=r Signature of Applicant
II\ l I Date
Owner or as nnved agent D e All roof coverings to be Class"B"or better
CITY OF CUPERTINO *
BUILDING DIVISION PERMITCONTRACTOR INFORMAATION..,,,�
BUILDING ADDRESS: PERMIT NO.05060097 5060097
OWNER'S NAME: PERMIT ISSUE DATE
LYNN CHING 08 /26 /2005
E: SANITARY N0, CON'MOI,NO.
ARCHOMC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo, .LICENSED CONTRACTORS DECLARATION Job Description
h S
i Z C 1 hereby affirm that I am licensed under provision of Chapter 9(commencing P
<U od with 7")ofDivision 3 of the Business and Professions Code,and my license is
in n mree,nd ermn. DEMO (E) HOUSE
,EI? Liceese Class Lic.N
F n Dam — Convenor y
i ARCHITECTS DECLARATION Nq�
oLI understand my plans shall W hired as public records J��!
8aU G '
Licensed Professional
3 OWNER-BUILDER DECLARATION p y B
f 1 hemhy affirm that I am exempt from the ConlnctoYs Lice.¢law for the
1:00 following mason.(Section 7031.5,Business and Prefessum Code:Any city or county
L2 F.. which requires a permit to consumer,altar,improve,demolish.or repair any moisture w- �e _ �� n 'Y/ $8000
Fi< prior as its issuance.also requires the applicant far such permit to file a signed statement
Em0
that Wislicensed pursuammthe provisions ofthe ContracwrsLicense Law(Chapmr9 Sq.Ft. FloorAfW' d� a UQ� Valuation
yl- (commencing with Scomy 7080)of Division 3 of the B usiousand Profestimas Code) �7 r1"r,
,92 thm be u exempt therefrom and the thou for the alleged computer.Any violauan of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 0( ��� /�' OccupancyT e
ore m
not man five hundred do[[..(ssfw). �r . � YP
O 1,as owner of the pmpcny,or my employees with wages u meth sole compensation, ��
will dotheworLand meswctum unatintended oroffcrtG fo=alo(Sce.7000,Business Required Iec[io�ns
and Professiory Cmc:The Communes U.Law does not apply m as.1 of e q ns P
property who builds or improves thereon,and whodoes such work himself or through his
own employers,provided mat such improvements are not intended marketed forule.IL
however,the building or improvement is sold within one yes of camplaion,the owner-
builder will have the burden of proving that be did not Wild or improve for purpose of
sale.).
O 1,as owner of the property,am=elusively contracting with licensed contractors to
consumer the project(See.7004,Business and Professions Cmc:)The Contractors Li-
ve Law does not apply to an owner of property who Wilds of improves thereon,and.
who contracts for such projects with a contrautor s)licensed pursuant to the Convactoh
License law.
O 1 am exempt under Sec. B k P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby air,.under penalty of perjury one of the following declimu o m
ve
1 haam will maintain a Certificate adornment to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the labor Cmc,for the performance of the
work for which this permit is issued.
O 1 have and will maintain Work,'r Compensation Insurance,as required by Section
3700 of dm labor Code,for the performance of the work forwhich this permit is issued.
My Worker's Compensation Insurance iota and Policy number are
Camcr. Policy No.:
CERTIFICATE OF EXEM iinON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit is forane hundred dollars($100)
or less.)
I certify that in the performance of the work for which this Permit is issued.1 shall not
employ any Person in any minority m as to become subject to the Workers'Compmainion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.,fur making this Cedifieau of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cade,you mum
.JO foMwi to comply with ouch provisions or this Permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
FI hereby Ifism that then is a comuucta.kndir ere— i .)nes far the rcrrarmana err
C the work for which this permit u tinned(sec.309'!,Co.C.)
W�q Lemer'e Name .
Z Lenders Addrtsm
U Q 1 certify Nat 1 have read W s application and sum mat the above information u
(y F-' correct.1 agree to comply with all city and county ordinamxe and some laws relating to
U building comwction,and hereby authadae representatives of this city to enter upon bee
r W above-menuonm property for inspection Purposes.
F y (We)agree m save,indemnify and kacp lu^nless the City of Cupertino against
rA liabilities.judgments,costs and expenses which may in any way reserve against said City
U z s Permit.
APPLICOUNDERSTANDS Aof the granting of ND ANTND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaData
HAZARDOUS MATERIAE DISCLOSURE Type of Roof
Will the applicants or forum building decorous mom handle amousmaterial
ss fm
dccd IM by Cupertino Municipal Code.e.Chapter
He
ter 9.17.and the Health and safny
Code,S,eiana553z(a)? All roofs shall be inspected prior to any roofing material being installed.
O Yes 0 N
Will mea scant or future WildingOccupant ant use t devices which or deviwhich If a roof is installed without first obtaining an inspection,I agree to remove
,..it nus air contaminants defined by IW Bay Area Air Quality Management all new materials for inspection.
District?ice?iconcontaminants as
❑Yes ON.
than mad me lcanmousmaterials mqulrencnts under Chapter 6.95 of Oc Califor.
nln Heal"Safety COds.Sectiov25505,25533 am 25530.1 understood!thmifine Wilding
does trot currently hart a bound,Nat it u my ,r=ponsihility to noufy the=upant of me
mquimmcntswhithmamWmetpriortniUUM=Of,Cen;ficateafacup.nty. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B"or better