04110098 CITY OF CUPERTINOtis�aa': rt'�' 'w*
BUILDING DIVISION PERMIT `CONTRACTOR"INFORMATION *..
BUILDING ADDRESS: Parm"NOb 4 11 0 0 9 8
OWNER'S NAME: PERMTT ISSUE DATA
GARY LI & ARETHA LEE
E; SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO O ELECT PMSCH
O
�0o LICENSED CONTRACTOR'S DECLARATION Job Description
OF I hereby alarm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 7 of dm Business and Professions Code.and my license is
jNin full roree and eff«I. ADD 10 01 SQ.FT.
2 Liu se Class Lk.e
g Dem Contraer
9 ARCHTTECI'S DECL.ARATIDR
I understand my plans"I he used as public wench
U
tad Licensed Professional
OatNEm BUILDER DECLARATION
F 1 herchy.(Su that 11. exempt from we Contractor's Cat:Any c Law for tiro
p O following moon.(Smtim 707 t.5,Business and Professions Cade:Any city or eo.ry
$ which requires a Permit to construct,alcor•narrow.demolish,or mpeir any structure I 587c;
i prior te its issuance.also inquires the applicant for such permit to file a aignedmmumac t
qq6 z< Nat heis licensed pu=.atmthe provi.awuofthe Cmaraemr',Lt. I..(Chapter 9 Sq. Ft.Floor Area Va cation
(commencing with Sedan 7000)of Division 3 of the Busineu and Professions Colt)Or
tlW he 6 eampt dominate and the basis lm the alleged exemption.Any violation of
Sudan 7071.5 by may applicant fm a permit subjects the applicant to a civil penalty of e30 0 Occupancy Type
not mare than R.hundred dollen(5500),
1,u owner of Nie popmrty,m my employs with wgo u thair sole mmpmudon,
will do Ne workand theommute isnot intended marketed formal.(Sm.7044,Business Required Inspections
and Pmfev)om mn Code:The Contractors LiceLaw does not appy m e ns an owner sur q p
property who builds or harvests thecon,and who class much work himself Or thmuth has
own employs,provided that such Improvements are not Intended or offend for said.If.
however,the building or Improvement is old within am year of completion.the owner-
builder will low tie burden of proving Nal he dad mor build m improve fm purpose of
ala.).
❑1.as Owner of the Property am exclusively contracting with licensed controon m
cause La the es net(Secapply
to an ownBuser
of and Refesaima Cade:)The Cs wencora U.
come Law does not apply m an owner of property acm(.who bulls ra Improves Neuron.card
whoonseLocomes.fm such pm}ersa with aeontrasmr(a)licensed pmaam m Ne COntrstOrm
0PIN
1 me law.
�1 am exempt undo Sec. .B At P C(m this recon
Owner Dam ARzz
.
s I WORKER'SCOMPENrurya DECLARATION �Dnv
IhembY alRrm under penalty of perjury am of the following declarations::
Ilaw end wall maintain a Cedfrau of Comm to self-insure fa WmkcrsCempcn-
soon,u provided for by Section 5700 of the labor Code,for we performance of Ne
work for which this permitis issued. . ® r .
❑1 have Sedco 37M
will maintain Workers Compensation Warmest,as required by S
5700 of the labor Code,for the performance of the work for which this Permit Is Issued.
Myrier, ,Cpmpensdonl any-N-0. number tae:
Carrier.--CCiib11LL!! '^ Poll ROM WOR ERS' •t—'
CE FICA Pr10N FROM WORKERS '
COMPENSA71ON INSURANCE
(166 owtm need not be comptemd tithe permit is froom hundred delan($I00)
or leu.)
1 certify that In the performance of to work for which Nis permit 6 issued,I shell not
employ any peron in any manner an as at become object m the Workers Compensation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making N6 Ceninae of Exemption,you shmld
become subject in the Worker's Compensation provisions of me Lino Code,you must
.,O forthwith comply with much provisions Of this Permit hall 4 deemed raveled.
Z"'•' CONSTRUCTION LENDING AGENCY
[�4 I ameby.M.Net Nem 6 a construction leading agency for the performance of
a > the were for which data permit I.issued(Sec.3097.Civ.C.)
QLenders Name
=z Lenders Address
U Q I certify Nn 1 have mad this application and sum met the.bow informal.6
U.F correct.1 agree m comply with all city and county amimmus and sum laws tattling to
G U building construction,and hemby authority repmenWiws of this city to enter upon the
LL7 above-medamcd property for Inspersion purposes.
(We)agree to aha•indemnify and keep harmless the City of Cupertino spot
}..�y liabilities,judgmem,,cmts and expenses which easy an any way arm against said City
in
U 4
his neft.
APPLu ANTeOf the UNDERSTANDStarting Of IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S EGULAMONS.
e� Re-roofs
SfSMu.of Applicam shown" ox -
NAEARDOUS MATE LS DISCLOSURE Type of Roof
Will the applicant or future bullding upon,ams or handle mammon material
as dented by the Cupenim Municipal Code.Chapter 9.13,atd the Ha1N and Safety
Code,Sued..35533(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �e
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II h.dnm sit contaminants as defined by the Bay Ara Aar Quality Management all new materials for inspection.
District?
❑Yes VNo
I have read the hasndmsmarnals requinamcnts under Chaper6.93 of the Collier.
nlaHmlm&Safety Cade,Scuart,M505.25533 and 35574,1ummntatd matifthe building
ds m ally Mw a m+tant.that it 6 my responsibility to mdfy tin oauput of de
mqu' or hichm4abcmetp�' rmaasuo/cadra CenmOcamof Occupoc, Signature of Applicant Date
�rr°3 All roof coverings to be Class"B"or better
Owner or euthariad agent Date