06020103 17
CITY OF CUPERTINO .ca�rq�ua+Kr ^si�+'- ^«mum .
BUILDING DIVISION PERMIT CONTR�GTUR Ir1FaRMATI0N "
BUILDING ADDRESS: PERMIT ND.
21839 LOMITA AVE
R'S NAME: PERMIT ISSUE DATE
GARY LI 03/30/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BO EQ PLO MEOCH
3Gj LICENSED CONTRACTOR's DECLARATION OF 1obDescription
1 hereby affirm Nal 1 Am licensed under previsions of Chapter 9(commencing
with Smile.7M)of DlvWan 3 ofto Business and Profession Code,and my license u
£'2 in full force and effect. DEMO (E) GUEST HOUSE/CARPORT/GARAGE
5 R jE License Class Lic.N '
;F Dam Comnctnr Fi■NTLE®
ARCHITECTS DECLARATION
I understand my entero shall he vud a public rtmrda
U
Licensed Professional
g OWNER-BUILDER DECLARATION
mom unm A Z 2 eQ
9<II heresy.(Sero That 1 A.1. exempt from she Cssions o License taw for the M Y 3 2000
00 following moon.(Season 7101.5,Business and n.,dosloli Cede:Any easy ar county
which its Ism a a e.alit ...omcs else impmw,demolbk or repot any tatapare
-��n Adorn ill tensed .nits rtquires the applicant for such permit n Nese Law statement
< (commincing edpuraentto thas Iwo)oroviotion3oftheBncnhldcenessw(CMPur9 $q.Ft.FIO Valu*600O
p flunhe is
cnefro70W)nf basis for
theaegedC Rand Kristian Code)of 1
$ Nat he u tamps thertfom and 0u bub for the alleged eanmption.Any violadan of 15111
Section
tone Nen fbby nonapplicant
plan mor a permit subjects the applicant n a civil penalty of APN Number Occupancy Type
01,u owner of the property,Or my employm,with wages As their sole ampeasnon, 35715153 , 00
will da the work a ad thestroctum b nut intended or offered for sale(Sec.7044,Business Required Inspections
and Poefeulon Code:The Consmctoes Littre Lew des not apply n e an owner of 9 P
property who bui1M ar imprmes thereon.and who does such wok Mmsel f ar through his
own employes,provided Nn such imprownenuare not intended croRered(malt B,
hawewr,the building or improvement is Gold within one yes of completion,Ne owner.
buildi will hams die burden of proving that he did nal build or impose for purpose of
ate.).
I.As owner of the propeny.am pdu ively contracting with licensed ceminuars to
mntoun do project(Sec.70x4,Business and Profession Cade:)The Continues V-
ceps:law does not apply in an owner of property who Wilda or improve Merton,ad,
who contracts for such projects with a contractor(s)0cenad p somam in the Cmarome.
Li ma taw.
olanexemplun (Set ,BAPCfarW moon
lhn Date ob
AOR S COMPENSATION ENSATION DECLARATION
I hereby am.under penalty of perjury an of the following declaretion:
❑Ihaw and will mainuinaCWResu of Conentnalf-inurefmWarkehCompen-
p0on,u provided for by Section 3700 of the labor Cade.for the perfonnanm of Me
work for which this permit is issued.
❑1 have and will maintain Workela Compensation Insurance,As required by Section
3700 of Ne Labor Code,for the performstte of the work for which this permit is issued.
My Worker's Compensolan Inavnnce eorier and policy number am:
Cartier. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This mc0on need not he completed If the permit Is fm one hundred dollars(S 100)
or lex)
I modify that In the performance of the work for which this permit is!load,I shall nm
employ any porn in any manna sops t8bycarg subject to 0e Workers'Compena0on
Laws of Callfamlt Dau- 4 f ,,LL.➢D.-y
Applicant baa`
NOTICE TO APPLICANT..If,after making this Oci ificate of Exemption.you should
become tubjeu in Me Wmku'a Compensation provisions of the Inbar Code,you mus
.J O TaMwith comply with tach provision !,s
or this pant hall be deere
demand wked.
Z 71 CONSTRUCTION LENDING AGENCY
y+ Isemby Arlon that tam ba construction hodinpgemY fm du performanceof
the work for which this permit Is issued(Sec.309'1,Civ,C.)
Q Iande's Name
z
Lender's Address
U Q i ttnify that I haw mad this application and use that the abase Information is
F COMM I agree to comply with all city and county ordinances and state laws relating n
(y
it, building ami m.1i.a.and bomb,authorise repruentaiws of Nis city to late, Pa.the
[i1 .trove-mentioned property for inspection purpmea
gt. (We)agree in saw.indemnify and loop harmless the City of Cupertino against
Try liabilities,judgments,cru and expenses which may in any my acme against aid City
tJ 7 In consequence of the ganUng of this permit
r1- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
3 ickRe-roofs
SigtmumifAppllmeaContmcher ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum building occupant store or handle harsrdan material
as defined by the Cupenino Municipal Code,Chapur 9.11,and ode Health and Safety
m,Schon 355310)?
❑Yu `�, No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or forum building accup rat use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haxodon air contaminants As deOncd by the Bay Arca All Quality Manahnaml, all new materials for inspection.
Conlin? ���aaa
❑Yen yNo
I hew mad the hsaodmts`materi ab requirements under Chou r 6.95 of the Calif".
nleHulthaSafety Code,Sudonsl5N15,75533and155M,IunderseuMNuiftk building
dues wt currently haw A unapt.that h b my noponlhithy in mrtify des occupant of the
reunions, hies muubemmisnorniuuaremora CeNficacof Occupancy% Signature of Applicant Date
R/y'l�)r�l- ��Ylsd V
Owner oramha a agent Dae All roof coverings to be Class"B"or better