06060012BUILDING DIVISION
BUILDING ADDRESS:
21820 LOMITA AVE
& HONG HIM LIM IPERMIT NO. 06060012
OWNER'S NAME: PERMIT ISSUE DATE
08/29/2006
PHONE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER:
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
rich Section 70M) of Division 3 of the Business and Professions Code, and my license is
n full farce and effect-
.icensc Class Lic. k F�
)ate + '" 1 Contractor ` ! A )9 t al l/ry<f r
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
.iccnscd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
allowing reason. (Section 7031.5, Business and Professions Code: Any city or county
vhich requires a permit to construct, alter, improve, demolish, or repair any structure
mor to its issuance, also requires the applicant for such permit to Glc a signed statement
hat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
commencing with Section 7000) of Division 3 of the Business and Professions Code) or
hat he is exempt therefrom and the basis for the alleged exemption. Any violation of
iection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
tot more than five hundred dollars ($500).
] L as owner of the property, or my employees with wages as their sole compensation,
,will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who doessuch work himself or through his
own employees, provided that such improvements are not intended or offered 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 for purpose of
sale.).
] 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier'Pr "6-6*—� 'Je_t`4-r2•iiri"I' L
. C_,: ,. t Policy No.: /,�r,7 S GPS-•'
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t`, k F EMPTIONFROM'WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workcrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name .
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building eonswetion, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way acerae againstsaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOL 4CE REGULATIONS.
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Date
HAZARDOUS MATERIALS DISCLOSURE
.Will the applicant or future building occupantstare or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
❑Yeslu
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Ycs No
1 have read the hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand thatif the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy., j
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Owner or authorized aecm Datc
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
ADDITION 552',REMODEL 8271,GARAGE 420'
REMODEL 827' X 100.75 = $83,320,25
Area
Number
T
ssued by:
Re -roofs
Type of Roof
Required Inspections
uatlon
$225332
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better