04060006 CITY OF CUPERTINO "rr {'sem g� yr���'' ' �r n
BUILDING DIVISION PERMIT
But DING ADDRESS: TOTAL CONSTRUCTION PERMTNO04060006
22 1
OW NEWS NAME: PERMIT ISSUE DATE
HEUNG SER PARK 136 CYPRESS
g; SANITARY NO. CONTROL NO.
(408) 781-3109
ARCHITECT/ENGINEErsR::� BUILDING PERMIT INFO
BLS ELECT
� PLUMB(� MECHO
fop LICENSED CONTRACTOR'S DECLARATION
1 hereby.farm that ase 11 it under rovitlans nr ChapI 9(commencing Job Description
< withSh tion] )of Division3of Ue,Buaincae Pro[cssions Code,end myliccnx is
.ia inmIf. deffeet. TEMP POWER FOR CONSTRUCTION
License asa Lic.g
�"O Date Com,ecm �DU
s RCHITF-CPSDECLAR N
Y 1 dem my plane shall W used as pas aNs
DayU
G r^ Lu:cnx0 Professional
OWNER-BUILDER DECLARATION
I I hereby affirm that I am exempt from Ne Comnclor's License Law for the - s,
O O following mason.(Section 7031.5,Business and Pmfesin.Code:Any city or county
K m which mquims s permit to construct.altar,improve,demolish.or repair any mructurt
'thy prior as its issuance,also requires the applicant for such permit o file a signed statement
y<
that he is licensed pursuant to Me previsions of Me Contrachn's Licemani Law(Chapter 9 Sq.Ft.Floor Area Valuation
is (commencing with Section 7000)of Division 3 of Ne Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any vi.[.Uan of
Section 7031.5 by any applicant for s permit subjects Ne applicant to a civil penalty of
not more Nan Ove hundred dollars(5500). BT Occupancy Type
❑1,as owner of Ne pmperty,Or my employees wiLb wages as theirsolc compenudon,
will do the work,and theswcture is not intended oraffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuacue s Liam Law dao not apply w e ns an Owner of q p
property who build,or improves thereon,end who das such work himself or through his
Own employees.provided thatauch improvements are mdurnanded aro@red formic,if.
however,Ne building or improvement is said within one year of completion.the owner.
builder will have the burden of proving Nat he did not Wild.r improve for purpose of
sain I,
C] reattachescomp \
1,as Owner of the property.am exclusively contracting with licensed reattaches m
c.asauel the es not (See.0 sh Rosiness and Profeso Wilds
Cade:)The Contrerion. rad
come law does not apply m ao.wnar of property who sed p or improves thereon,and, \
whocontractsLa tsfar such projects with acontracror(q licensed pursuantwthe Contractor's r
0 1 am Law. C�
❑taco exempt underSec. ,B@PCfor this reason `v^
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby of inn under penalty of perjury one of the following declarations:
have and will maintain a Certificate,of Covent to self-insure for Worker'sCompen-
mtion,as provided for by Section 3700 of the Labor Code.for Ne performance of the
work for which this pamft is issued.
❑L have and will maintain Worker's Compensation Insurance,ke required by Section
3100 of Ne Labor Code.for the performance of the work for which this permit is issued.
My'
y Wor ars Cnmpenwlion lnaumna artier end Poliry uflnr�bcr art:
Cam S t - Polic 1J
CERTIFICA OF EX Pno WOR ERS'
COMPENSATIONINS RANCE
(This auction xetl not becompleted if the permit is Throw hundmddoltsm(SIM)
or less.)
1 anify Net in Ne Prof.....of Ne work far which this permit is issued,I shall not
employ any person in any manner so as m became subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Code.you must
Q O forthwith comply with such provisions at this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
[rte I hereby affirm Nat th,re is a construction lending agency for Ne peffennarece of
CL> the work for which this permit to issued(Sec.3097,CN.C.)
WQ Lendeh Nmnc
M
6 7-. Lenders Address
U Q I certify Nat L have read this application and sure,that the above information is
correct 1 agree to comply with all city and county ordinances and Stam laws relating to
Q building construction,and hereby authorim representatives of this city to enter upon Ne
G above-memion,d property for inspection purposes.
(We)agree to save,indemnify and keep harmless de City of Cupertino against
rF.e N liabilities,judgments.casts and expenses which may in any way same against mid City
C)ti IAnPPLICCAeNT of the DERSTANDSof this AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOURCE jG LA N 6/0
0 D
Re-roofs
MrApplicant/CorkesigtoI canUCo
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant.,future building scup..[stare or handle h' us materiai
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
We [3Ye,2ss3z(an A(1 roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building.aupont sex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
n its
icu nus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
7 C/
❑Yes Diu
I have mad the hvaNnusmawrials mquiremcnts under Chap erfi.95 of dm Califor-
nia Hwith&Safely Code,Settlors 25505.25533.425534.1 momenand thou!the building
Jots not cu t y have a te...4 that Il is my�tt�essponsihiltry w notify the occupsnt or the
requtrcmc ichmus mm rwisairw EC'muficateof ,.Pas . Signature of Applicant Date
�V� 6 S d All roof coverings to be Class"B"or better
Owner or authorized agent Date g