03110027 J
F CUPERTINO .. �x�'ass.m * + ,- }a-v�,
DING DIVISION PERMITC®NTRACTt�l2INFORMATION 40DDR17SS: RAY CHAN PERMIT'003110027
ME: 16615 LOREE AVE PER.MITMUEDATE
CHAN 1 OS 2003
SANITARY NO, CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSEDmatIamCONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job DBS1
< with Section 7M))of Division 3 of the Businca and Profession Code,and my license is ANALaIts®
M imm�romeandeffect. WINDOWS & SIDING ^�
j n z License Class Lim.g
F Dam Contractor Nov 1 9 2003
e¢¢ ARCHITECTS DECLARATION
C d 1 understand my plans shall be used as public menrds
5yU
eq Licensed Pmfeasinn°I BUILDING
OWNER exempt frDECLARATION
d O 1 Wrathy reaso affirm that 1 am exempt from Nro Cations Co License Lew for the
❑O fallowing mason.(Section](131.5.Business and improve.
de nm Code:Any tiny m county
$ which its is s a permit rmanco,also e vires the eller,improv,h Permit t or e a sig any swcmot $1400
priohe ns iacensedpursuant to the
theapplicantfor sucContrarminLicense Law(Chned apter
�m Natmencccnsd pursuant )of Divine of the Comranur'snd Professions
roelaw(C odc)or Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 the
the Business and on.Any
Codc)or
$
that he is exempt thert(mm and the buts for the alleged exemption.Any violation of 37519004 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom than R.handled dollars($50D),
P Y YP
❑ I.as owner of the propeny,or my employees with wages u their talc compensation,
will do the work,and the swaum is net intended oralfemd fond,(Sam.7W.Beat.
end Professions Code:The Convectors Licenm Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own cmployess,provided that such improvements are not Intended or offered for sale.If,
however,the building or improvement is sold within one year of eompinion,the owner
builder will haw the burden of proving that W did not build ler Improve for purpose of
sale.)..
.a owner of the property,am exclusively contracting with licensed coronation to
construct the project(Sec.7044,Business and Refusions Code)The Cento co ri Li. .
cense Low does not apply to an owner of property who builds or improve Ihemon,and
who contracts for such mjcca withacomrenor(s)liccnudpunuent LOMConwCtor's
License Law.
❑lare saempt re. ,B&PC/far 01,m an
Data rr
\ KER'S COMPENSATION DECLARATION
1 ereby afft under penalty of perjury one of the following declarations:
I have and will mai main a Certificate of Consent o self-insure far Workers Compem
anion,as provided for by Section 37M of the Labor Codc,for the performance of the
work for which this permit is issued.
rl 1 new and will maintain Worker's Compensation Insurance,as required by Seclion
3700 mf the UdWr Code,for the peHmmanee of one,work for which this permit is issued.
My Workers Compensation Insurance caner and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tho sectirn need not be completed if the rare it Is for one hundred dollars($100)
m nus)
I cmify that in the performance of the work for which this Permit it issued.I shall not
employ any person in any mannerso as to become subject to the Worker'Compensation
Law,of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifcaa of Eacmption,you should
become subject to the Worker's Compensation provisions of the Isbmr Cade,you must
.,O forthwith comply with such Provisions or Nis permitahall M deemed revoked.
ZC CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency tnr the performance of
the work fur which this permit is issued(Sec.301 Civ.C.)
W ALender's Name
C.
z Under's Address
U Q I minify that 1 haw read do,applies,box and sats the,the,bow informniun Is
ty fpr toren.I agree to comply with dI city and county ordinances and sate laws relating to
0U building cammuetion.and hereby authorimmpresenatiws or this city to enter upon the
Ibl .hove-mentioned prepeny for inspection purports.
gy (We)agree to save,indcmni fy and keep homeless the Ci ly of Cupertino against
F gq
liabilities,judgment",costs and expenses which may in anyway accrue against said City "
U z in consequenec abbe min (thin permit.
APPLICANT UN Dg AND WILL COMPLY WITH A{{..L NNN���NPOINT Issued by: Dale
SOURCE REG r/ /r1�
/J Reproofs � O-3
Signal titan ontr¢mr Date / ( //
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Lir furore building e,Chapter
9.1 or handle Health and
u defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety10, '
Scc yen 75537(,)? All roofs shall be inspected prior to an roofing material beim
❑rex ON.
P P Y g g installed.
Will the apPlienl or future building occupant use equipment atdcviccs which If a roof is installed without first obtaining an inspection,I agree to remove
It bo's'om air contaminants n defined by the Bay Am.Air Quality Menagcment all new materials for inspection.
ivriet,
❑Yes 0 N
I have mad the haeNnus materiala requirements unJer Chepmr 6.95 of the Calif.,.
ria H..IN&SafetyCak,Seem.25A)5.25533 uu125534.I understood thin ifthe building
Docs not cure a tesrQq that it is my maporuihit ity m mruly nM mcupann of the
requirements mustbc• ismi an cupany._ Signature of Applicant Date
owner aatho e,.d em Dam All roof coverings to be Class "B" or better