02110104CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT
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5Uu2110PETESMC CLELLAN RD
PERMIT N102110104
MONIh+IP YEN & IRENE KUNG
APPLICAT11N1SUB 9Y2002
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I'IIONE;
SANITARY NO. CON BOL NO.
ARCHITEC/lINGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions lir Chapter v (commencing
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S I ON- - IN El8 %9crt9T ONLY
with Section 7Uth of Division 3 of the Business and Professions Cole. and my license is
in full forecandeffect.
NO NEW
PERMIT ISSUED
I.iccne Ctas.. I.i,:. "CmUUc
nate
OR I G.#
0 2 0 6 014 3
DECLARATION
TS DECI
ARCIITIbe
Use
I unJecaunJ my plans shall tin us=J as public recorJa
Licenced Prolemional
OWNER -BUILDER DECLARATION
I hereby alfirm that I am exempt from the Contractor's License Law Ia ithe
following mount. (Section 7031.5. Business and Professions Chair: Any city or county
which requires a permit En consumer. alter. impro.e, demolish, lir repair any structure
prior but issuance, also requires the applicant for such Permit o file a signed summent
that he is licensed pursuant to the pmvi:ions of the contractors License Law (Chapter 9
Sq. Ft.
Floor Area
$90019[00@tion
(commencing with Section 7000) of Division J of the Business and Professions Gose) lir
that he is exempt therefrom and the basis for the alleged eaemption. Any violation of
e
Occupancy Type
Section 7131.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than Eve hundred dollars ($501).
1, Us owner of the PmMrty, or my employees with wages M their sole compensation,
equved Inspections
will do the work. and the structure is not intended lir offered for sale(See70W, Business—
and Professions Code: The Contractors License Law does not apply m an owner of
102
- PIERS
rods mimpmvesthereonand who arcnsuctende oroffrmself edthroughhis
property provided
Own
OwndmoBercJ [orthe
not ear
suchment
employees. ping lit
103
— UFER
ow. r.f.
is saements
or impressat
nott year or completion. the owner.
ovcmcnlis Within of
104
— REBAR
wthe ill et he
builder will have the burden of proving inn he did not build or improve for purrysc of
the burden
sd 1, .Bemms; comncdng with lmTheeConnuacmn tu
❑smer
105
106
— ANCHOR BOLTS
- SEWER & WATER
thepojct(Seeproved,
conmmatheproject(Sec.o an Businessandprofessions Cudi TheContractorderon. Li
and
«naLaw drcanoupplymanowner ofpmpertywho luJaaorimproveathemnn.and
202
— UNDERFLOOR PLUMBING
who contracts for such pmjecm with a contractor(s) licensed pursuant to the Contractors
203
- UNDERFLOOR MECHANICAL
License Law.
❑ Iom exempt Under Sec. ,B& P C Ilii this reason
204
- UNDERFLOOR FRAME
Data
205
- UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
301
- ROUGH PLUMBING
I hereby affirm under Ish.lty of pedo,, otic of the following dedarehom:
302
- TUB & OR SHOWER
1 haw and will maintran a Cerrificau, of Consent to arlf.inadhm for Worker's Compen.
.he.. as provided for by Section 3701 of the Labor Code, for the performance of the
303
— ROUGH MECHANICAL
won for which this Permit is issued.
304
— ROUGH ELECTRICAL
0 I have and will maintain Worker's Compensation Insurance, as required by Section
3 05
— FRAME
3700 of the tabor Code, for the performance of the work for which this permit Ls issued.
My Waiter's Compensation msennce amok, and Policy numberare:
306
- HOLDOWNS
Carrier: Policy No.:
307
— INSULATION
CERTIFICATE OF EX EM VFTON FROM WORKERS'
COMPENSATION INSURANCE
308
— SHEETROCK
ction need ambecompleled ifermit iaforonc hundreJdollum,(SIg)
(ThisuoW p
309
— EXTERIOR LATH
,it leas.)
310
— INTERIOR LATH
I certify that in the performance of the work for which this prould is issued. ) shall not
311
- SCRATCH COAT
employ any pertain in any manner so as to become subject In the Workers' Compensation
Laws ofCalifornia .Date
313
501
- ROOF NAIL
— FINAL ELECTRICAL ENERGY
Applicant
NOTICE TO APPLICANT It, after making this Ccniticmc of Exemption you should
become subject o the Worker's Compenmion provisions of the UNIT COUR. you must
502
— FINAL PLUMBING ENERGY
forthwith comply with such provisions or this permit shall he deemed revoked.
503
— FINAL MECHANICAL ENERGY
TNG AGENCY
CONSTRUCTION construction
I alitrm that there is aconmmudon lendmgagancr nn the peHtnmana Lir
504
- FINAL BUILDING ENERGY
the work for which this permit is issued (See. 3097, Civ. C.)
Lrodcr's Name
505
506
— FINAL ELECTRICAL
— GAS TEST
Lenders Address
I ccnify that 1 have read this application and scale that the above Information is
507
— FINAL PLUMB ING
correct.I agree to Comply with all city and county ordinances and sure laws relating to
building construction. and hereby nut cutis representatives of this city m enter upon the
5
FINAL MECHANICAL
above property for inspeninn porous.
09
FIN
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
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liabilities, judgments. costs and expenses which may in any way aectue against mid City
5
FN G
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in consequence of the granting of this permit.
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by51
I
WORKS Date
SOURCE REGULATIONS,
Re -roofs 603
Type Of P444
— OF BATTENS
— ROOF IN—PROGRESS
Signal.. Of APPlic..VConl... Date
HAZARDOUS MATFR1ALS DISCLOSURE
Will the applicant lir future building oa'[upanl store .,handle LI.Noes material
defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
e.Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes C] No
If a roof i5 installed
without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
into hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
0Ycs No
1 hall: read the hazardous materials requirements under Chapter 6.95 of the Cali for
nia I RIM & Safety GWe. Sr"ons 25505, 25533 and 25534.1 understand mac if rhe building
rows not currently have. tenant, that it is my rest msiMlhy w notify the twcupanr of the
requirements which must he met print co issuance of a CeNfcam lir Occupancy.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
Owner oraumori..edagent Date