05120136 CITY OFCUPERTINOa ;? a +di4.'dE ���' ' '`" �' • "� :?,
BUILDING DIVISION PERMIT �CON R4C'1�f1UI�1 F011,
BUILDING ADDRESS: PaRMiT NO.O 512 013 6
21915 LOMITA AV
WS NAME: PERMITISUEDATE
E
LUMIN CHANG 05/22/2006
FFMNE: SANITARY NO. CONTROL N0.
ARCHMECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
3o6 LICENSED CONTRACTOR'S DECURA71ON Job Description
IIm Nn I hereby afnr1 am Ilacmnd under provisions of Chapter 9(commencing
with Section T01K8 of Division Sof that linemen and Prefcssium Code,and my flura a is
Limnfame and eGaL ADD-1, 200 ' 3 BEDRM/2 . 5 BATH/KITCHEN/FAMILY RM
i'qz License Class LiatO or DRIVEWAY-GARAGE 425 ' - REMODEL 800 '
F$p Dam C7SDECL
f4As Bandl use DECLARATION
GG< landerwnd my plans siWlMutndupublic recmrda
U
e Licenxed Professional
`e Oat I am exempt ro DECORATION
I Iemso ,Ritm that 1 am exempt from the fc oscuns License law for Nc
COO which following muoa(Scotian 7031.5.sru Business and vefession Code:Any city or county
9 which its iresits.•permit re coWe atter.Improve,h permit t of a,ir any twcmm
-i y Psior a its i erased p also requires tothlM Applicant o Wefor such nation ro Bm,sLwJ SW peter 9 Val a31(I5�4 7 0
that he is licensed Punumtmthc provision of We Coronation's LJcanx law(Chapter Sq.Ft.Floor Area
E�C (commencing with Sudan 70110)of Division 3 of Ne Business and Prarmions COW)or
C4 $ that he b exempt lhemrrom and Na bub e alleged exemption.Any vloladafor Nn or
Sutton 7031.3 by any applicant for a permit subjects the Applicant an A civil Peneby ofpM068 . 00umber Occupancy Type
Am,...mare dun Bve hundred dollars(5500). 3 5
❑1,As Owner of the property,Or my employees with wages As their sale compenssdon,
will do the work and the awcmm it.9 lomrwnd or afferW for sets(Sec.7W,Budneu Required Inspections
and Pmresdow Cane:77e Comamofs Liunse Taw docs act apply m an Owner of q P
property who builds nim pow thereon.and who does assn auric himsd f n Nmugn his
own employm,providnd thetauch improvements am antNundM"offered fm sate If.
however.the building or improvement b sold within we)ear of cmnPleumn,We—
builder wig new the huNen of poring that he did rot build m improve fm Purpose of
sale.).
1.a owner of W Property,Me exclusively conuamin{with Licensed conuwmn m
commm de 64
project(Sec.70 ,Business and Profession Cade:)The Commences Li-
cents law docs at app,m era owner of property who builds or improve femora,and,
who contracts fmaunh prokro with a canuaciarU)Buried punwm m de Connotative,
License o
0 I me exempt un See. Bh PC far Nis moon /
ter /-'WORKER Dae
ffi COMPENSATIO ECLARATION
l bemhy,M m underpewlty ar perfmY elm of de following declarations:
Q I have and will msinuin•Cenificeu ofCowent m wlf•inum(m Wohcls COmpeo-
radon,u provided far by Sudan 3700 or ft labs Cade,fn'a perfarmuaa of the
woh for which Nis permit is issued.
1 haw and will mainuin WortrYs Compensation Iwannce,As required by Sudan .
370D of the labor Code,fm Ne performance of de wmk for which mus permit is bound.
My Worknfa Compensation htmrartu Univ and Polley number am:
Carrier. Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
(This semlw wed wtbecampleted If the permit it forone hundrnddollus($100)
or hes.)
1 cattily,Nat In the performance of the work for which this pmmlt is lewd.I shall not
employ any penan in anym�rm Oslo hemmcibj^c�WWorken'Campenmlw
wnt
Laws of California.Dstq„w S- 6
Appll �' sz 4
NOTICE TO APPLICANT:if.after making Nb Ceninwm o mption.you should
become subject It,the WorteYs Compensation provision of the labor Code,you mow
O forthwith comply with such provisions m Nb permit Mail be darned revoked.
Z y CONSTRUCTION LENDING AGENCY
Fn I hereby slnrm dot them is a consmrttim,lending agency for de performance of
C> the work for which tun permit Is issued(sea.3097.Civ.C.)
WW Q Landers0.
None
PLanders Address
U O 1 unify that I have read NmNa
is application and m t the above Informationb
fy F caned.I agree As comply with all city and county ordinances and Ane laws miming an
�U
building construction,end hereby authorize mpesrem,ows of this city to enter upon the
abovcmentiuned property for inspection purposes.W (Wa)ague to save.indemnify and keep harmins We City of Cupertino against
CA liabilities,judgments,cold and expenses which may N any way name against mid City
(„)`Z in unsuaeme of the{.do,of this permit.
APPLICANT UNDER NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R GU S.
�` -2—�d Re-roofs
Signuum pfAppllwnl/Cwtrecmr Dam
HAZARDOUS MATERIAM DISCLOSURE Type of Roof
Lu&I Will Ne Applicant m future building occupane t Maor handle hu mow m,erial
Lu de0ocd by de Cupertino Municipal Code.Chapter 9.13.and Ile Health and safety
.9eNeus3zU)7
Oyer ,
❑rAll roofs shall be inspected prior to any roofing material being installed.
/ 'a If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building Occupm use equipmem or devices which
mall hmndnas air contaminants a de0nea by the Bay Am Air Quality Management all new materials for inspection.
District?
❑Yea /��R/p
I have mud the Inwardness mamdalsrequimments ummrChapter6.95 of Ne Califon-
as
alifon
nb Health k SafmyCode.Section 75505.35533 and 35534.1 understand Nuifde Wilding
dura not cmrentl ane a ftML Nat II b my maponlblllty u neufy de occupant Of de
mqulmmcn mm be met pilar trance of,CertiOcae of Occupancy. Signature of Applicant Date
owwrar,athanyea,gen, Dam= - All roof coverings to be Class"B"or better