04030195 CITY OF CUPERTINO �*-" Ate'
BUILDING DIVISION PERMIT CONPRACTOR TN�'�RMPI.TIONA
BUILDING ADDRESS: DWK CONSTRUCTION PERMIT N0.04030195
ER'S NAME: PERMIT ISSUE DATE
ON CHONG
NE: SANITARY NO. CONTROL NO.
(408) 615-1508
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
you LICENSED CONTRACTOR'S DECLARATION
1 hereby Affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description
with Section 7M))or Division 3af the Business And Professions Codo.and my licenseI �-
mmBfo=andA t. py EVISION-- OUNDATION
5 License C Lt.k
a p Dam Cnmtanmr 7 IT ISSUED/ORIG. #03080015
YARCHITECTS DECLARATION
1 undcramnd my pl
Y ace.hall M wed as public momma,
30 Licensed Porimmonal
S OWNER-BUILDER DECLARATION
I hereby Al7rm that 1 am exempt from the Co lool.e.License Law for the
O O following meson.(Section Aa 1.5,Business and Profeaions Code:Any city or county
$ which requires A Permit In construct,alter,improve.demolish,or mpsir any structure
Fify^
Into,tu its isouac ,mau require,the applicant for such permit to Elea signed auument
pp C Nu he is licensed Footstool Wthe provisions ofthe Common's U.noeLaw(Chapter 9 Sq.Ft.Floor Area Valuation $0
k (commencing with Section AAD)of Division 3 of the Business and Professions Coda)at
Net be I.exempt therefrom and the bat for the Alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of ASN Number Occupancy Type
Am mom than five hundred dollars($500).
❑1,a owner of the property,or my areployces with wages a Nei,mole compensation, 37513028 . 00
will do the work,and dte abuctute is amintended oroflered fonds(See.7044,Business
and Professions Code:The Conuacmrs License law dans not apply in an owner of Required Inspections
property,who buildsorimpmves thereon.andwho does.uch wankhimalforthrough his
own employees,provided thatsuch improvements tie out intended oroResed finale.It.
however,Ne building or improvement is Suld within one year of completion,Ne owner.
builder will have the burden of proving that he did not build or improve for purpose of
❑1.as owner of the ve
property,em exclusively contracting with licensed Conctors to
const evA
censtmd the Project(Sec.?nano owner
ofI and Professions Cade:)TheCommitteesthe on, n '
coos law docs not apply a an owner of property who Wildsro improves Norton,and
who cantrsdafor such projects wiNaconwnor(q licensed pumanlm the Conlnctah \�
Lon US
lam exempt under gee ,BRP fmN m�arnn
at Dam v U' �7
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of Perjury one of Ne following declarations:
1 have and will maintain A Cenificam of Consent to self-insum for Workers Cumpem
sation,An provided for by Section 3700 of the Labor Code.for the performance of Ne
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,AS required by Section
3700 of Ne labor Code,for the performance of the work for which Nis permit is issued.
My Workers Compensation Inaramen artier and Policy number am:
Carrier Policy No.: -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(itis sec0an need not hccomPletd if the lcrmit is fnronc hundred dollars(SIM)
or less.)
1 certify that in the Performance of the work for which this permit is issued,I shall not
employ any person in any manner an a in become Subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with Such provisions or this Permit shall W deemed revoked.
z "" CONSTRUCTION LENDING AGENCY
,r-t4 I hcmb,.M m that Nem is a eonstmctinn lendmil.gemy for the performance of
C> me work for which this Permit is issued(Sec.3W7,Co.C.)
Q Lender's Name
=z Lender's AM.
U 0 1 certify that I have mad this application and scam Nat Ne above information is
Fcorrect.1 agree to comply with all city and county ordinances and sum laws mlming to
U building construction,and hereby audoorim representatives of this city to enter upon the
` W above-Amni mncd Property for inspection Purposes.
(We) gone in ave,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,casts and expenses which may in any way acerae against aid City
U 7 in mnaqucnee of the gnnlir,of this permit.
G� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALt,NON DINT Issued by: Date
\ SOURCER CULATIONS,
Re-roofs
Sign um Af Appl,c.uContrecmr Dat
HAZARDOUS MATERIALS DISCLOSURE Type of ROOF
Will the Applicant or forum building occupant store or handle haardous materiel
AS delmod by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
e.Section s 3ss3z(an. - All roofs shall be inspected prior to any roofing material being installed.
C]Yes ❑Nc
Will the applicant or future bonding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haramous air contaminants ns defined by Ne Bay AMA Air Quality Management all new materials for inspection.
District?
0Ycs ❑Nu
1hAvecoedthe herardresm M505,25533 and
255under Chapter6.9595 of the Calling
nia Health R SdctyCade,Scctiom 33505.35577 and 33530.1 undersand thazifihe building
Jaen oat cuncntly ham a tenant Net is 4 my responsibility m nodi des occupant of the
requirements whi mnmt be met prior to issuance of a CcrdOat o Dean Ir. Signature of Applicant Date
���"'" ce?, 3
Owner or authorPred agent Dat All roof coverings to be Class"B"or better