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BUILDING PERMIT CONTRACTOR INFORMATION:
BmLDINOAI%NUi40 MAXINE AV KWOK PERMITNO
OWNER'S Y.W LJK APPLICATION SUB DA'1'li
IONF: t1�t� SANITARY NO. CONTROL NO.
HUILDING PERMIT INFO
O�p ARCHITECI7ENGIN[ER: BLDG '.F.CT U MRCH
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NZw I_I —I
F y�' LICENSHU CONTRACTOR'S PECLARAHON Job Description
OZ=o I hereby off f thw 1 um IicenwJ under prnvisinns of Chu,tcr 9(mm�ncncing
zw F•m with Section 7(Nxgnf Division 3oflhe Business and i'mfe.oinns Code.and my license
m^� Is in foil fame and eflml.
z a< License Cleo Co M
x 9 n u Date S DECLARATION vc a G ABCIIrrECre DECLARATION
Ela 1 undcmanJ my plum xhall he used as puhlic rtcoNs ,e /
sf a o o I.iem,ce Prone„i„nal WATER HEATER
,a.o P OWNERdtU1LD1FR DFCLARNI']ON
el_ 1 hereby iodine mm I am exempt rnnn the Contmdm's hlcm,..Law lar the
C Z a following moon.Sold un 70115.I3ueincss and T ofes.ine,GNe,Any cily or na.nty
2 F M which requires a permit to comlrvcl,offer,improve•denu ll.h.or repair any swcmm
ca
to prior
its issuance.also requires the appliced for such pandit m file a signed statement
a. that he is licensed pursuant to life prodsinns of contractor.Licen.a Law(Charm,a Sq. Ft. Floor Area Valuation
(commencing with Solon 7000)of Division,of the politics,and Profession.GNe) $1000
elitist he is exempt thamlrnd and the basis for the ollcged exemption.Any violation
of Section 7031 S by any a„licrm for a pcomi, chyso,the opplicam to a civil parally
of not mora than live hundred dollars($5(X)). A,NN694. 00 Occupancy Type
❑I,.—wase,of the pngery,or...y mnployce,wlaf wages ns thei nate unnpemmien.
will Jo the work,and the droll c is not intended or offered for sale(Sec.7044.
He1me1,and Prrfe„ion,Cars. the co,nmemr's Lieeme Law does at,,apply 10 a., Required Inspections
owner of property Who builds or improves mercer,anti who does.such work hin,selr
or through his awn employees.provided mm men improvement,arc net intended or
oRered for sole.IL however,the building or improvement is cold within enc year of
completion, ownerbui'lderwill havefhe Wadenofproving that hedid not build or
improve 50^e — FINAL PLUNKING ENERGY
.
C L ayowneroflhe property ame.ela,ively contracting with licensed commcfnis to 506 — GAS TEST
Limomft he p,9ir.a(zee.7u4.Hu,imo,and Proreyao.f,C«m:)The Coo 507 — FINAL PLUMBING
es cLawdor un.q,ply ,,anownerofpro"'iy who builds),lmproes�hemon,
nod who romrrcis for,nch Projects wan a um.....odyl (forced Farm I lo efe
Contmeuds Lieensu Law.
O 1 nm exempt under Sec. .H @ P C fur this ri,voin
Owner NS
WORKIiR'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations v r
] I have and will maintain it Certificate or Consent 1n sel Ginsure for Worker',
Cumpen,mitr as provided for by Section 3700 air the Labor Code, for the
perl'ornnance of the work lin which.his permit i,issued.
❑1 hive and will maintain Worker's Compem:nion Insurance,a,required by Section
370)of the LaNa Code.for the performance of me work for which this permit is
,sued.My Workers Comlemalbm Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(I la,scrawl nuW if...be completed If the pm nit is for hundred collas
($10(1)or Iso,.)
1 certify that in the performance of the work or which this permit is i.ssued.l
In not emplay y per n any manner m,o( become abject a the Workers'
in
A? sof inn ill.1)a
Applicnm
NOrICETOAFPLICANT: der making this Certificate of Exemption,you should
Monne abjecuo fine work ' Compcnwfiun provisions of the Labor Core,you must
O forthwith comply with,self .suns or this permit,hall be deemed revoked.
z .
CONS'I'RUCfcon.LENIN NG AGIiNC1'
aIherebyair s,mat mem is ii cmxedic.n 9Jins nsancy Iso the Perfi,m,:nec .
W of the work!r witch this Iermit is issued(Sec.30097,Civ.C.)
G z Ldnder's Name
., .z nder's Address
V C I codify the 1 have mad Ihi,application and state,lou the above information is
fa. r caned.I agree In comply with all city and coumy ordinanms and state law.retailing
V to kidding mmraaior.:md hereby authorize representatives of this city to ether upm
me above-mentioned pmperty for inspection purpna,.
tiIy (WoO nose to coc,Iodemniry and keels handles,me Cayof Calvenino nguin.m
Z I'mhilitic,juJsnsms.1-111,and upfnw,Much may In any way untrue against sold
V z City in consequence of fir granting ed this Femti
APP.ICANT tNUI?R 'ANDSAp'IyWILLC01'LY WIT14 ALL NON.POINI' Issued by: Dale
S RC Nir ,U 5 N' f� a I� y'
gem o PPlicapol car —'y Dafe Re-roofs
IIA] )ODS MATERIALS DISCLOSURE
Will the applicant o future building oaeapanl mso or handle ha:adote material -Type of Roof
as dclinN by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safe,,
Cole.Sm1icn 25532(X))'!
Cres 0N _All roofs shall be inspected prior to any roofing material being installed.
Wonsan,ficam... acem ouldfirfloced,aotfraegwpaffmo,desire,wldel, If a roof is installed without first obtaining an inspection, 1 agree to remove
.mil hmaMous air amfaoo:n 1,as Jclined by the(fay Arca Air Qurltry Management
Ddliell es ❑Na all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read the hwunlous materials requimnrcm,under Chapter 6.95 of the
California Health A Safety Code.Sections 25505.25533 and 25531.1 understand that
If the building does not cnmcmly haves mosso, a it is.ny responnibilirymnmify the
(spam nr the rfyni rams which ma,1 be.rte Prig m issuance of a Cenificme of
O"r'd nfy. Signature of Applicant Date
Ownntaraumodaedasc t Dmf All roof coverings to be Class "B” or better
OFFICE