03080015 ;BUILDING
TY OF CUPERTINO
Drvlslory PERMIT CONTRACTOR INk'UitMATION `DING ADDRESS: DWK CONSTRUCTION PERMITN010308O015
8 VVER'S NAME: PERMIT ISSUE DATE
CHONG 1646 S DE 2003
E:
SANITARY NO. CONTROL NO.
(408) 615-1508
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0
, LICENSED CONTRACTOR'S DECLARATION
U Job Description
w F1 hereby afrrm that 1 am licensed under provisions Of Chapter 9(commencing OESCII p
`v with Section 70fMpof Division Sof uleB csaand Professions Code,and my license is
imm�m �aq{erren.� QrzoA2 NEW 1 STORY SINGLE FAMILY DWELLING
3:I j License CW3s �R(l.�,_
Dyd=.;
b Cannanorj/ I{�TL{{j}ar E 1832 . 5 SQ. FT. /GARAGE 432 . 5 SQ . FT.
e4Q ARCHITELusedas ARAFIOblicmco
C 2 I undersm my plans shell M used ea public renxdx
>yU
a. LiccnuJ Professional ,
S OWNER-BUILDER DECLARATION rte U( 4
Mf 1 hereby afrrm that 1 am escmpt from the Contractors License Law for IM1D tR �oOl " . -
p o following mason.(Section 7031.5,Business and Professions Code:Any city Or unty
`<S� which mgmm.a permit to cnnsuua, no,improve,demolish,nr repair-anM an
azr mormits iwuancc,also mquircs the applieam for such permit.rlcasigne u rat
<
that he is licensed pmruml1.the provisions more Cmrtmcmr's License lsw r9 1%1LL) t oar Area Va�l�,tgo0pp-
Yts—$ (commencing with Section]O(0)n(Division 3 of the Business and Professin d '
Nat be is exempt therefrom end Be basis for the alleged exemption.Any violation
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally or APN Number _ r 'Jeeupaney Type
not marc than five hundred dollars(5500).
37513028 . 00
❑ 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the swctum is not intended or offered for sale(Sec.7044,Business
and Professions Code:no Contractor's License Law does not apply man Owner of Required Inspections
Property who builds or improves thereon.and who dues such work himself or through his
own employees.provided Thal such improvements are not intended orolTemd for sale.IL
however,the building or improvement is sold within one you of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
.to)
p 1,as owner of the property,am exclusively competing with licensed contractors to
construct the project(Sec.7044,Business and Pmossione Code:)The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves themon.and
who contracts for such projects with o contractor(s)licensed pursuant to the Connector's
menu Law.
I am exempt under Sea .B&P C far this..an
net Data
WORKER'S COMPENSATION DECLARATION
1 hereby afrm under Penalty of perjury one of the following decimations:
I have and will maintain a Cenificme,Of Consent to self-memos for Worker'sCompen-
ammn,as provided for by Section 37M of the Inion Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permil is issued.
My rkeYs Compensation Insurance Unfair and Policy number am:
c Policy
CERTIFICATE OF EXEMPTIOW^OMWORKERS'
COMPENSATION INSURANCE
(This sectmn need not M completed if the porrah is for one hundred dollars($)M))
or less.)
1 certify that in the performance of the work for which this permit is issued.l sholl nut -
employanyPe rat any manne`,dfj, ecymesub',hitothe Workeri Compensation
LaaPvCo�cfCalif mm ate `r��77 dd''oo _r���
NO'IJQEtTO ATPP : .alter m cnifinm or Esemptmn,y' -ou ahudld
become subject to the Worker's Compensation pmvisions of Ne Labor Code,you must
= O forthwith comply with such provisions of this permitshall be deemed mvnked.
tiCONSTRUCTION LENDING AGENCY
'pr I hammy affirm that there i..consuudinn lending agency for the performance of
x me work for which this permit is issued(Sec.JVP,Civ.C.)
W� Q lender's Name
Lender's Address
U I certify that 1 have read this application and state that one above information is
lL F correct.I agree to comply with all city and county ordinances and state lawn misting to
C U building conswctice,and hereby sermon,mpmsentmives or this city to enter upon the
a .hove-mcntimed properly for inspection purposes.
f~ (Wc7 agree to save,indemnify and keep homeless the City of Cupertino against
N liabilities,judgments,costs and expenses which may in any way aceee against said City
U Z, in consequence of the granting of Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
SO E ULATIONS.
�v-a3 Re-roofs
gnamrc ofApplicaHAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or future building nompant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode.Section 255320)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea O N.
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
tit hamrdoas air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
fairan
ict?
❑Yes ( 'o
1 have lead the hnardous materials requirements under Cha ou r6.95 of the Califor.
nia Health&Safety CMU,Seen=25505,25533 and 25534.1 understmd that if the Nilding
dues not curuntiy have a tenant,that 11 is my responsibility to nobly the occupam of the
commonenka which sal Wmel Ptiormiste enra Ce for to ofOccupancy Signature of Applicant Date
All roof coverings to be Class"B"or better
Own,of ammi.dagem at,