06060149 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COI�ITRAC'I,9,RANFC}RMATION.
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BUILDING ADDRESS: CALVIN NG & HONG HIM LIM P"'LMITND'06060149
21820 LOMITA AVE
0 NER'S NAME: PERMTr ISSUE DATE
CALVIN NG & HONG HIM LIM
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: _ BUILDINO PERMIT INFO
BLDG ELECT PLUMB MECH
loll LICENSED CONTRACTOR'S DECLARATION Job Description
�t 1 hereby affirm del 1 am licensed under provlsiau a
of Chapter 9(censenci 11 p
with Section 700M of Division 7 of she Business and Professimm Cade.and my license is
in full fares and affect HOUSE DEMOLITION
License Clea Lk.N
Date Conlrutor
nig ARCHITECTS DECLARATION
j @ I understand my plans shall he used as rotate meads A/
s�
G Licensed Pmfessianal
y� OWNER-BUILDER DECLARATION
0 0 I hereby atnnn o that 1 1. ,Bump,hum the Cssions eco License Any c Law far the
:00 o fallowing mason.(Saito Tan L5,Business and w.de tins Code:Any city or county
i$ which requires a itennit m ctmsua,,Alla.impraw,demolLsh,or repair any axntemm ;7000
-z 1 dam Ire is
iaswm0.abu in
sin tbnvislo c of far ash permit w ck se Law stateme 9
(comma lkgwithSrsuantcadreofDiviansofthe she
dProelaw(Chapter9 Sq.Ft.Floor Area /�� on
`�$ (comets exempt
ptthecon7 and Li basis Division al Budnwandon.Myovi Code)or
thax M V exempt titerefroro and the beta fa the alleged esemptian.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant an a trail penalty of r cupancy Type
not mom than five hundred dollars(5500k
❑I.as owner of the property,or my cmploycer with wages u their sole compensation,
will do the woric. itton awcmmi. a,Intended waRamdmraale(Sex.Ta4,Business Required Inspections
and Professions Code:The Conun ecmes License Law class not apply m an owner of q p
propsny who builds or impwwsd arcon,endwho daeaouchwork himselfor Brough his
awn employees.provided that such Improvements are mtimeMed aro@red farnk.U.
however,Ne building or improvement is mid within one year ofcompledon.the owner.
Wilder will low Ih burden of proving that k did rot beim a improve fa purpose of
Villas 1,ru owrcr of the(Sec.
Bexclusivelysineseal emuasions with UaneW oonaaams m
momconstruct the esaproject(Sec.in 4.Bmrnta aM property
fessionswho,builds
Cade:)The Cmu¢mfa U.
and untie ossa dons am apply c an owner of pvpenY who builds err imprnvm Ihroon,and
whocontractsLace for ash Projects with sanuanor(U licensed purnunt m the ConuaaoYs
License Law.
❑I am exempt underB S P C far Nis mason
106
WORKER'S COMPENSATION DECLARATION
I hereby aUlrm under penalty of perjury not of the falmwing declaradons:
❑I ham and will mainainsCenirsate croissant in selfdmum(ar Wofte3Compen.
sation,as provided fa by Section 7700 of the Mbar Cade.for the performance of the
work for which this permit is iaad.
❑1 have and will m intim Warklrs Compensation Incomes.as required by Section
3700 of the labs Coda,far the performance of the work for which this Penni,h mad.
My Workeh Compensation Insurance carrier and Policy number tie:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section mad not be completed little:Permit Is foram hundmddellan($100)
or tat)
1 aeifv Nat in she performame of the Lark far whkh Nb m h is iwmd.l stall not
cmplaymyPmerti.. mlyt orae bjectlodnwoftw Compiramin.
Lawsof Califamia.D., uug j.
Applicant a
NOTICE TO APPLICANT:If•after making this Cimilmanto of Exemption,you should
become subject w mo Workers Compensation previsions of the Labor Code.you a=
Z forthwith comply with such provisions;or this permit shall be decreed revoked.
„Zn O CONSTRUCTION LENDING AGENCY
[-n I hereby affirm than there is a construction lending agency for Ute Performance of
0.! the work for which this permit Is issued(See.3097,Civ.C.)
Wry Q Lender's Name
= z Lender's Address
U0 1 certify that I have read this application and sum thin the above information is
it, F corms.I agree in comply with all city and cowry oNinanas and state laws relaxing In
0U Wilding commuction,and hereby•umorim npresenutias or this citywanterupon the
>4 W abovrmcnuuncd pwpcny for rnspcnkn purposes
g� (We)agree m save,indemnify and keep harmless ft City of Cupcnino against
E. (We)
liabilidea,judgmena,caa and upgums which may In any Lay some agalmt mid City
U Z in consequence of the granting of this Permit. /t-.
r APPLICANT UNDERSTANDS NO WILL COMPLY WITH ALL NON-POINT Issued by: -'('Date J &
SOURCE REGULATIONS.
' �� Re-roofs
Signature of Appliam/Conicm
m r Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building aapmtuom a hurdle haeadoea material
as dcRmd by the Cupertino Municipal Cade.Chapter 9.11•and me Health and Safety
.Section 255314)? All roofs shall be inspected prior to any roofing material being installed.
pyo
Will tho applicant or future building occupant use equipmeal a deviw which If a roof is installed without first obtaining an inspection,I agree to remove
emit huxudnns air cunummanta as de0md by me Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes GJu
I have mad the hmamous materials nequimmems under Chapter 6.95 of the Califor.
nu Health h Ssfcty Cade,Sauons 25505,35577 and 25534.1 n demand thin lithe building
does ml cannily haw a meant,that it ig my responsibility In Iwtity,the occupant or the
requirements which mus,eq�etdarmiemana aft cmmrmate or soman
1,5764 Signature of Applicant Date
Yl S
Owner or aumouud asem Data All roof coverings to be Class nBn or better