03070013 [Of
ITY OF CUPEW1'INO :, t*�-x✓ ��'•'n'-' " °� '
IBUILDING mvlsmN PERMIT CON TRACTOR-IN FORMATIION
LDINGADDRESS: C & E WU/ K. & J. CHIU PE"n" 030700I3
t
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. fi� '19 CONTROLNO.
ARCHITECrENGINEER: BUILDING PERMIT INFO
BL ELECT PLUMB MECH
+Op LICENSED CONTRACTOR'S DECLARATION Job Description
�U 1 hcrchy affirm that I am licensed under pmvisions of Chapter 9(commencing
m� wish Sectimi7M))ufDivi.tcA 3.f the Dutlness end Prufessinns Cociaend my license is
j�=o. infuuforce,and effect. DEMO OF POOL
License Class Lic.A
'^q Date Contractor
ARCHITECT'S DECLARATION n tL
sd I understand my plansahOl heusedes puhlicrccnNs �It1tt��+trp�
DiU ��d
+a Liccnscd Pmfcssionei
COo OWNER-BUILDER DECLARATION 8 2p03
D Mrchy.((Section ns 1 t. excmpl from me Comraera's Any Lew fur the II11
po whichrgmssoaermitt1onstr Bu alter.and Professions Code:Any oily mmuum )
3 m which requires permit re enns..l,alter,improve.for
demolish,m maxis any+tm.larc _- -w
_I< pnonnita issuance.a6u requires the applicant for such armiuo file asigned statement
ggm mel he is licensed pursuant the provisions of the Conlmcwr's License Law(Chapter 9 Sq. Ft. Floor Area Bue�. BVfitllauOn
yFo (cam mencing with Section?")in Division 3o the Business and Professions Cndc)or
i $
that he U exempt Ihemfrom and the basis for me alleged exemption.Any violation of 34229006 . 00
Section]m1.5 by any applicant terapermit subjects the applicant t9 a civil penalty of APN Number I Occupancy Type
not more men five hundred dollars($500).
L]I,uowner of me proany,or my cmploycea with wegeu Meir+ole compcnullon,
will do the work,.Ad tM+..lure is not intended orof..d forsel.(Sec.race,Business — Required Inspections
end Pmfcmd.As Cade:The Conttulors License Law does oat apply W an..net of q p
progeny who builds or improves thereon,and whodoessuch work himself or Ihrougb his
own employee,provided that such improvements are not intended oralfered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve fur purpose of
sal,.).
I ner of me progeny,em exclusively contracting with licensed contractors to
ren the project(Sea'!Wd,Business end Professions Cade)The ContaeWr'+Li
cense law doe not apply to owner of property who WilW orimpmvu lMmon,and,
wha a-m-oca for such projects with•contractor(s)licensed pursuant W tM Contoaah
License Law.
❑lam ex apt under Sec. .B k P C for this lesson
ner -�" Data V
WORKER'S COMPENSATION DECLARATION
I hereby dr under penalty of perjury one of the following daleralions:
I have and will maintain a Certificate of Concent W at insure for Workers Compere
,ion,u provided for by Section 3?00 of the Labor Code,for the performance of the
work for which this permit is issad.
❑I hale and will maintain Workers Compensation Insurance,as required by Section
37W of me labor Cods,for the performance of the work for which this permit is issued.
My Wodefs Compensation Insurance artier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Todds section need not beeomplcted Lithe permit is foram,hundred dollars($100)
or Icsa.)
I certify that in the arrormanec of the work for which this permit is issued.I shell not
employ any person in any manner m As W become subject o IM Woheri Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ccndiaie or Exemption.you should
become subject W the Worker's Compensation provisions of the Labor Code,you mum
.J O foMwi th comply with such provisions or this permit shall M deemed reward.
'Z CONSTRUCTION LENDING AGENCY
(+ .4. 1 hereby affirm the dare is a consuation lending agency Lot the Kohnmaae of
!Yi 7 the work for which this permit Is issued(Son.7097,Civ,C.)
W Q lenders Namc
Z Lcndces Address
O 0 1 certify than 1 have read this plitiemion eAd mame that the ehovc inf.rmed.o is
ly F Cancer.1 agree to comply with all city and county ordinances and sure laws relating to
0 U Wilding construction,and hereby Almomw rcpraemmiwa of this City to enter upon the
a eh.w.rderlimacd property for Inspection purposes.
(We)agree to eve,indemnify and keep hasmleu the City of Cupertino against
.F. In Liabilities,judgments.co+ta mdexpcnses which may in any wase emcee against mid Ciy
_UZ Incon+eganccofdin grand.,;ofthis pc.it. -7
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: late ! 1�
SOURC LATIO
?1-11'42 Re-roofs
igna o pplice14 CZARDOUSMATERIALS DISCLOSURE Da Type of Roof
Will the applianl or ruur,Wilding occupant mora or handle hvardous material
U defined by the Cupertino Municipal Cade,Chapter 9.12,-and IM Health and Safety
Coals.Section 25532(M?
❑tics ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
( it hazardous air contain mania a defined by the Bay Arco Air Quality Management all new materials for inspection.
Litter?
❑Yes 0N
I haw read the hamdous materials requirements under Chapter 6.95 or d¢Ceti(.,.
n' Ith&Safety Code.Sections 25505.25533 and 2553x,l understand that if the Wilding
a3 mol eurtcntly haw.arrant.out it is my 2sParxibility to of,the..'am of On,
mquirt hicnmust�bc Per nannnissuu¢carACerdfcamofOcapm . Signature of Applicant Date
V
Ow
authimind agent I.PAll roof coverings to be Class"B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: �e ` � - Date: 7- 1 —
V — / — 3
Job Address: k9 6.2' 1 d 'ka)0_2V� DY Permit#
�jb,
Any changes to the information provided on this form shall be submitted to the City of C Rvertino Build
Department.
X304 00/3
CITY OF CUPERTINO
IWOF DEMO
CUPEkTINO PERMIT APPLICATION FORM
APN# 2 Date:
Building Address:
o c �Y �il� o fid. Sol
Owner's Name: Phone#:
Contras or: k e. -Y pcta er cwi Z) License#:
Contact: v Phone#:
Mr. DO
A Contractor:
BuildinP rmit Info: \
BldgElect ` Plumb Mech
Job De 'ption: l
R ential: nun tial:
Sq.Ft. Floor Area: —1 /' $/Sq.Ft.:
Architect/Engineer: Wuati n:
Type of Construction: Occupancy G oup•
. if
A lit le Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
VO