06020037 CITY OF CUPERTINO "7 e_ &l"u
BUILDING DIVISION PERMIT � Q "�TZ ;.
BUILDING ADDRESS: PERMIT N0.0 6 0 2 0 0 3 7
10387 MIRA VISTA AV
R'S NAME: PERMIT ISSUE DATE
MARTHA KANG 05/18/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BURRING PERMIT INFO
'BLDO ELECT PLUMB MECH
30929 LICENSED COMRACIORSDECLARATION 7obDescrition
with Sec
! I hereby affirm Na 1 Am licensed under provision of Chapter 9(wmmenclnt P
Section 7")of Division 3 of the Budaaa and Profeaiuns Colo.and my license is
+�= kmBfomeandefrem 3 a 11 SFDWL-2 STORY 3 , 780 ' /GARAGE 483 '
I a U
am
Dir
ARCHITECT'S DECLARATION
ECLAR TIO
ad my plans hall
be used as public mora
6
�oG Liawed Pmfraiaal
'y3 OWNER-BUIIRERm DECLARATION
COna" 10
I hereby.Huns on 1 em aempl s an site Cosine, o License Law for the
o o fallow re mean.(Section 70311 Business end .duaoa Code:My City Of vesture $837S50
coo
9 which requires•permit re cares the aha.m rotimpsee dcmmW.s repair any sea en,
-z> pd.Ronheiu ienedpurs pursuant
the apions.l far such Permit Limas Laedaum.9
c Naheklingeih srpsammdepmvi Wns 3deconlaaemr.dPmr=i. ChaMa9 Sq.Ft. Floor Area Valuation
(commecis exe mW sec rid,and
of basis n 3 mf the eg dneernd Professing Code)or
$ Se becis 31.5 b my cep li antl Na aper res do alleged exemprim My violation of
Action 7031.5 M airy aced Mi far s(a permit subjects de applicant ro a civil prntlty of err Occupancy Type
mot mom than five hundred tla1Ws(1500).
❑1.as awner of the property,or my emplayw wed miss as deur mk comprwden,
wmout da.,it.And the atmem.1..tintended ororteredfor sak(Sm.70".Resineaa Required Inspections
and professions Code The Conuacto(a License Law don ant apply At an owner or 9 P
progeny who builds a im prows dvuemon,and who does such work himvlf a through his
awnemployen.provided Nat such Improvements art not Intended"Offered for Asia U.
however,Ne building"improvement is sold within arc year of completion.the owear.
builder win have the hookers of proving that he did not balk m improve fm Purpose of
al.),
❑1,As owns of the property,am aclaiwly contracting with licensed watradas ta
ungnsect the pmjca(Ss.7044,Business and Professions Cade:)The Cootracta(a U.
.Law does rot apply An an owns of property who builds or improves Nemem.And.
who convects for such projects with a conusctar(s)licensed paeasn u the Contractors
License law.
❑lam aemptundarsec. .B&PCrorthiamawn
Dau
WORKERS COMPENSA710N DECLARATION
1 hereby aMm under penalty of perjury one of the following decalWons:
❑I have and will maintain a CsotiBamof Consent an self-Iaum for Woda(aComPen-
nation,an provided fa by Section 3700 of Use Labor Cade.for the performance of the
work for which this permit is issued.
❑1 have and win maintain Workers Compensation Insurance,a required by Section
3700 of du Labor Code,for the performance of thtwork for which Nu permit la used. '
My Wmien"jCompensation
ImInssuuaws,cc�atrrier and Policy numb"am:
Carrier. %'-' • - ;R Policy No.:
(per sCEaTIFICATE OF EXEMPTION FROM WORKERS' ,
f��'''`t�CCOUMPENNETION INSURANCE
(This atria wed smthecompleted irthe permit is furtme hundred dollar($100)
or loan)
1 Unity Not in the performance of No were for which this permit is issued.I shall not
employ anyperen in any mannerw As k became subject to the Worter'Campeaadon
Laws of C31il miA.Deck
Applicant
NOTICE TO APPLICANT:Ir,after making this Certificate of Exemption,you should
become subject N the Workces Compeuedon provisions of Na labor Code,you must
Oforthwith comply with such provisions or this permit shall be domed reveled.
CONSIRUCrION LENDING AGENCY
F-s (hereby, ..thn der k a emutructi,kadingageney for the performance of
Uj
ft Ont for which Nis permit At issued(Sec.URI.Civ.C)
aQ Lenders Name
z Lowest Address
U Q I certify dot I have mad this application and state Na tM above information Is
w F corm I agree N comply with all tiny and county aokkaaes and sun laws mating to
OU building construction,and hereby amhodm rprecnusiet or this city m enter upon the
G ahove-menuound pmperty far inspection purposes. 11
(We)agree no eve"indemnify and keep harmless the City of Cupertino against
tF N liabilities,jodgmems,eau and erapenan which may In my my arose against said City
U z in J
cogequeme of the ung of this prnnil. j� 4
APPLICANT U NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL
Sf6� 6 Re-roofs
SiSomme of App1iwnUCd Dau
HAZARDOUS MATERIALS DISCLOS a Type of Roof
WIB Ne appliam Or future building aceupataore ar handl harasdon nowmial
As defined by the Cupertino All .Pal Cade.Chapter 9.13.and the Health and Safety
Section 255324)7 /6tttp/\ All roofs shall be inspected prior to any roofing material being installed.
Oyer
lthe applicant or fumm building mnmpant use equipment of device which If a roof is installed without first obtaining an inspection,I agree to remove
emit haardous air conumimnu a defined by the Bay Amo Air Quality Management all new materials for inspection.
District?
❑Yn site
I haw mad Ne wourdmu,n„^riaurequimmcnu underChap e,05 of do Califor-
nu Ha1N&WctyCede.Sctiats 25X13.25533 and 25334.1 undersand thalfdo building
dna Out currently Tuve a count.Na It u my responsibility m unify do acapant of the
mgeiroments whkhm met Prior k uwancc of a ccrufiaa or Signature of Applicant Dale
All roof coverings to be Class"B”or better
Owner or mnborind agent au