05120017 CITY OF CUPERTINO ^F�r�mze ,L+'��.df"M">r�L>r'i
5 BUILDING DIVISION PERMIT ;Coir lAn�CT"GWI4�F,-O
F39
ING ADDRESS: PERMIT N0.05120017
R'S NAME: PMtMrr ISSUE DATE
EILEEN PENG 5,1
SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
'BLDG ELECT PLUMB MECH
0
lop LICENSED CONTRACTOR'S DECLARATION Ib Description
I bunny a(Iirm that 1 am Ikeased Anchor provisions;of Chapter 9(commencing I
eing p
with Section 70 MB ofDivlalan 3.1'the BuAd—aM Professions Code.And my license is
In fan forcer efrem BATH IN (E) LAYOUT, .
m
Lia `°"° Lm.g
Dau Contractor REPIPE FOR WATER HEATER
... ARCHITECTS DECLARATION
Q I understand my plain shall he used As public rtmtls
awl; Licensed Pmfessianal
e�
OWNER-BUILDER DECLARATION
1 hcmby ARlna the 1 am tempt from de ContractNs License law for the
OO following mason.(Section 7031.3.Business and Professions Codc:My city of aunty
5$ which requires a permit in co rsomt,alb.Improve.demolish.or repair my structure
prior m its issuance,aim requiv dte applicant for such permit m file a signed statement
G that he la licensed pursuant m the provisions Of the Canummer Liccme law(Chapter 9 Sq.Ft. Floor Area Valu igm 0 0 0
mmurn mmi;with SecOan7000)of Division 3 of the Business and Professions Code)or
thm exempt 3 at he therefrom and de basis fm the alleged esemp0on.My vmImI,A.of
Section 7031.5 by any applicant fm A permit subjects the aPPECAn w A civil Penalty of APN Number Occupancy Type
nm roam than five AaMmA dollus(sans).
36919037 . 00
O 1,u owner of the property.or my employee Nth cages as Jeb ink campewtion,
will mthe work.and waatmeum4mtintended ororteredfor wa(Sm.7 .Bupmae Required Inspections
14 Plak"Ins Cad.-Tim Canmmmm ma
Ya License LAw does apply m l C an Amer of
propeny who build,m imprawa thermn,nth whod ssuchwcrkhimmlfor Waugh his
own employers•provided thatsuch improve sem Am not Intended oro0amd fmaal.-B.
hoxvm,the building or improvement Is sold wlthinons year of cempledon,the aw wr-
buildcr will have time buNm of proving th.t he did nm ddlo ar improve for pmpom of
sale.).
T(
I,u ownor of the property.Am exclusively conuacting with Beemetl mnumtorA On
construct the projen(Sec.7044.Business and Professions Code)The COMRanmYa Li-
some Law does rot apply to an owner of pmptry,wbo builds m improv thereon.and,
who contracts for such projects with a eonumtans)licensed pursuant m the Cmummts
License law.
❑Ism exempt undo See .B k PI C_for
thhe/m_ucce
Owner O DOOAA/ .Q�Dau I I
't /`* ERS CO PENSA N OECI.A D. I 1
I hereby aEUm under penalty of perjury rote of the following kx1aradons
sin and will mdnuin A CeNOem of Consent to Alf-imam for Warkeh Compen-
on,u provided for by Section 3700 of the labor Code,for the performance of de
wmk for wMeb this permit h iamtl.
❑I lone and will maintain Worke/s Compensation Insurance,u aniu ed by Section
31MV of the Labor Code,for the pmrmcnane,of the werk for which this permit is issued
"W
Compensation 4tmranmce artiar and Polley numbs art: .
Carder. Polb:y No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Crahzer mreed Amon completed Elite permit is form hundred dollars($1011)
or leas)
1 cmdfy that in use pcfformana of the work Ins which Nis Permit u(sued,l Nall nm
emPloy any person in any mmrcrm u m become mbjmt m sae Wm1mO,C:Pensatwn
Laws of Califomia
Applicant_ —
NOTICE TOAPPLI .1.after ma mg the 11cate of Excalipmon.you should
become subject an the WaheYs Compenss0on pro i,ions of the labor Code,you must
wJ O forthwith comply wlth a- provulans or Nu per It shill he deemed invoked.
'z'y CONSTRUCTION LENDING AGENCY
[-n I hereby alihm that des is a conttroNnn lending agency fm the Pestammatwr of
the wink for which this permit Is issued(Sm.3091•Civ.C.)
W� Lenders N,me
z Landces Address
U O 1 certify that I haw red this application and rote Nat tho above information is
tL;'" carecL I agree In comply with all city and county ordinarues and Aute lave muting In
0 building construction,and Aemby mthodx mpresenutiv of aus city in enter upon Ne
W above-mendomd property for WPeNon PurPoms.
Ly, (We)agree to ave,indemnify and keep harmless the City of Cupertino agaimt
m fajl liabiliim•judgamummmandeapeom,which may In anywayuauc apimtaid Wy
inc.0 Z
APPLICANTr UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGQLAnONS.
�Llt.eenv14 /cS Re-roofs
Sign.,,...olApplieMCZARDOUS MATERIALS DIS SURE m Type of Roof
Will she applicant of future building oemPant Aare mhmdle helNam mamral
A,donned by tie Cupertino Municipal Coda.Cupter 9.13.and sae ImAm and Solmy
'Cale.Section 35533()7 All roofs shall be inspected prior to any roofing material being installed.
ld%
❑Yin 1♦,S No
WIII the applicant or future building omApant mo equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
halArdmu,air conuminanu a defined by Ne Bay Area Air Quality Management all new materials for inspection.
ln7
Ihavemadsaehasandousmamdali rMimmenuderChpmr6.95af1heCalifor-
Wthd:SafelyCode.Smtiw25505.25533uW25534.lundmwi WtMifdebuilding
rot curmmly haw a mwmL dist It u my reponsidlity m Amity 0e omupmt of t e
irements which must W m 'or inumce o(A cerificam 0( p Signature of Applicant Date
All roof coverings to be Class°B"or better
er car authadrrd agent Dam'
Community Development
10300 Torre Avenue
J Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�PE�TINO
Building De artment
JOB ADDRESS: PERMrr#
R31 Mille)L, Ave, c o 1/2L � 7
OWNS 'S NAME: e I I PHONE # 408=253-3go-5—
GENERAL CONTRACTOR FAX #
s G �'+ 408- 314- 0&9z-
I amnod using any subcontractors: 12--5--05-
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring- Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet'Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
op, _ lz-s-os
Owner/Contract •Signature Date