04010040CITY OF CUPERTINOP,`
BUILDING DIVISION PERMIT
CC0NTRACTO�,NFOR MATIO
BUILDING ADDRESS:
STEVEN & HOSANNA CHU
PERMIT NO 04010040
ER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I Wreby affirm I am.fronted under provisions of; 9 (commencing
p
with Section Tlg1B) Divixion 3 of dte Businmx and Pvfcuions Codc. and my license is
o" Codc
in full force Liccone Classnd street.Lie.Y
ADD 26 SQ. FT. /REMODEL/
DatcContractor
ARCHREC I S DECLARATION
1 understand my plans shall W used as public memos
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alum 1 exempt from she Contractor's License Law for the
following reason. on 7031,5,Business and nm Code: Any city os county
maso 1, o my
which a permit re Consumer, fee. de or
Permit t repair any nmcmrc
eller, imfor
its issee tel,
h Permit t
such
prior m its i licensed Pursuant also requiree IW applicant foe such panni' m file a signed sutemcm
(commislicensed b) provisions of the
Sq. Pt. Floor Area Valuation
effen7 eBusinessnd Profssor(Chapterm1c)or
ns Cmlc)of
(coOat Dndia n3
Pt.
Ilial he is
he is exempt rmfonlflnd the al aged exempt Any violation of
the Any
thcmfmm and dr aper for the alleged caemant
section subjccathe applicanuoacivil Penalty of
31.5 b a to
3MIt9OWe.00 Occupancy
no, veany undredionlfor
not marc than five hundred dollars (5500).
(S5W).
pe
❑ 1, u owner of the pmpcny, or my employees with wages as their sole compensation,
will do dm work. and Ne structure is not intended or offered for sale (Sce. 7044, Business
and Pmfessions Code: The Contractor's License Law docs apply to in
Required Inspections
not owner of
builds improves
property who or thereon, and who doessuch work himself or through his
own employees, provided Nal such improvements are not interrded or offered forsale. If,
however, the building or improvement is add within one year of completion, the owmr-
builder will has the burden of proving Nat he did not Wild of improve for purpose of
r
1. n owner of the am sed confession, with to
Seopeny,
comma a Bassinets and Professions Code:) The Cornu
not (Sec. ss and :) The Counselor's
es o an
acme law docs not apply to an owner of propenY who Wilds or impmvex'hemon.end
reon. std
who.).
contracts for such pmfeGle W1111aCOn V]LIOf(a) IC[nYd pursuant 10 the COOVBLIafe
a-
Liceme law.
Lic
(] 1 sm exempt under Seo. , B & P C�forr�Nhis/masonn
Data 1 //w1mY
p�
WORKER'S COMPENSATION DECLAR TION
las
Ihemby&Mtmundcrpenaltyolperjuryam Ofthe Coll n, declaotions:
I have and will Maintaina CcniOcam of Consent m set imine far Worker's Compcn-
/
talion, as provided for by Section 3IW of the labor Cade, for me PCRmnaoe Of the
wok for which this permit is issued.
O 1 has and will maintain Worker's Compensation Insurance, u required by Section
37W of the labor Code. for the performance of the work for which this permit I. issued.
My Wark,e, Compensation Imad .. carrier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
(Thr secliml need not hecomptowd if'he permit is rmonc hundred dollars (Slg))
less.)
1 certify Na' in the performame of the work far which this Permit is issued. I shall not
employ any person in any manner so as In become subject o do, Workers Comperradon
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making Thr Ccnifcoo of Eacopsion. you should
become subject to the Workers Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this perm,l shall by deemed mvokcd.
CONSTRUCTION LENDING AGENCY
1 hereby pM m Nal there is a comuuetion lending agency I'or the performance of
me work for which this permil is issued (Sec. 3097, Civ, C.)
lender's Name
Lenders Add.
I certify tho 1 have read this application and sum Net the shove information is
Correct. I agree to comply with all city and county ordinances and sum laws relating to
Wilding comomelian, and hereby authariu mpmmmalives of this city in enter upon the
shove-mentiomd Property for imlrchr n purposes
(We) agree In sae, indemnify and keep humlcu the Cily of Cupertino against
liabilities, judgments, cosi end expenses which may in any way accme against said City
inconsequence of the 6nn'ing of this permit.
O
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
I/
Issued by: Date
(1
SOURCE R ULATIONS,
/
Re -roofs
nmuma pplianVContrac'or Date 11
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant ur future building Occupant store or handle havardous Marcos]
a defurcd by One Cupertino Municipal Cede. Chaplcr 9.12. and be Health and SafelySection
`
0Y.X.25s3z(a)?
Yes
0' k.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
coil haiardous air contaminants u dirmod by the Bay Area Air Quality Management
District9
all new materials for inspection.
❑Yes u
1 have mad dm WdaMousmaorn.1s ,lonmmcnts unikr Ch,pter6.95 .(OC Califon
Of. Heal" SaR yCade, Sections 255)5, 25533 it 25534.1 undersand Nalifthc Wilding
tires not currently base a tenon, Our it is my maperaihili'y sly de meuPwl or thc
which mus' be mel Poona issuance Ofa Codpcate0 LpanLy.
Signature of Applicant
pmquiremcna
si-- f//z/ey
Date
All roof coverings to be Class "B" or better
a nerorauthmined.,,of `� Dale r