05060116 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �G0NTRACT0R4NF0RMATIION`. .
BUILDING ADDRESS: PERMIT N90 5 0 6 0 116
20634 NANCY CT
VERS NAME: PERMIT 15810 DAR
KRIS WANG 2005
ONE: SANITARY NO. CONTROL NO.
ARCHIIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
e
2i0o
LICENSED CONTRACTOR'S DECLARATION JobDescri tion
1 hereby,fOrm that I atm licensed under proviaioua of Chapter 9(commencing P
with Section 7070)of D ivi.ion 7 of the Business And Profession,Code,and my license is
in hen force And elfm ADD 6301 (FAMILY/STUDY) REMODEL
zg-' L1cns°°e
Date C KITCHEN & 2 BATHRMS
coon r ,
CHf1ECl'S DECLARATION
I mWenund my pies shall he used u public records
3 NQ.KE roll gI1AANg�
t� Licevetl Pmfessionel
OatNE.acemOER DECLARATION
0 0 I berohy.nice that I I.S.esud from the Conaanoo License city
A for Ibe -
O O fallowing reason.(Section 703 usnt.afwArmmpr Rofaaiom Cade:Any city or County
$ which requires a Issuance,aim on wmuuet atter,improve,demolish.m repair ed mumum
F- P
prior e,II,lcensedaimrequitestbevision nt rat such oftheConne utOornkseLaw(shapterl 6®1652
�< that he tscing wtl peau nil me provisions Soft Contranturi Licenmlaw(C ocle)m Sq.F[. Floor Area Vallfja
q� $ (eommcneing with Section1l") Dlvidon7nf me Busineuand Profcuinns Cnde)or
IC — Nu he is exempt therefrom and me but&for the alleged exemption.Any violation of
Section 7031.5 byan,Applicant for.permitsubjeeu the applicant in.&H penalty of APN Number Occupancy T
And more than Rw hundred dolls,( oo). 3 5 915 0 3 5 . 0 0 P y y�
orm
❑I,sa owtsr of Ne property,or my employees with wages As ducksak compensation,
will do Os work and me&net..ianotintended oro0ered rot Ne(S.C.7011,Beat=& Required Inspections
and Professions Code:The Contractor's License law docs wt Apply m e an owner of q P
property who Wildsm improves maremm.ndwho doessuch work himxelfor Mush his
own employes,provided that such Impre emwu.rt notintended onofrered for sale.If.
budder,the new
the or improvement ts meld Whin ms year o i m row our me ode of
builder.th hoe me burden ro ement I that he did rot build or Improve for purpose of
oak.).
❑i,a owuer or the property,,m a mess t ly can usidong with:)Tibc Crontraoon m 411g,
� ,
"to.).construct 0te protect(Sec.7014,Business atM Pro(esalam Code:)Tic Contractor's W-
ccnsa law does not apply m An owner of progeny who build,or improves thereon.And
who Contracts for such pmjcm with A eonractm(G licensed pursuant in me Conr,mof, a /P
License Law.
O latnexemptundef See .BAPCfrthisruon
lvr Dale
WORKER'S COMPENSATION DECLARATION
1 hereby Anne under peulty of perjury one of the following dechoulorm
❑1 bmand will mainW n aCutifiws of Convent mal(-luaurt Ion Workefs Compere- [[II(� ((�.tll
ration,As provided for by Section 3700 of the labur Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,As required by Section
3700 of the labor Code,for me poor.....or me work for which mu permit Is Issued.
My Workers Comsensstion Insulin a curer W Policy number am:
Carrier.�y�Li���11 Policy No.: �I ?il— .�fJUQ
CE IF 0•EX• PTION FROM WORKERS'
COMPENSATION INSURANCE
Thtssecdon need not mcomplemd time pewit Is forom hundred ddlm($100)
lir leu.)
1 certify that in the performance of the work for which this permit is Wood,I Nail nea
employ anypermn in my mannerso As an become abject to the Worken'Compeue0on
Lows of CaiiforldL Dau
Applicant
NOTICE TO APPLICANT:IL after making this Ccnincom of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code.you must
.JO forthwith=reply with men provisions or this permit shall be doemed moked.
zCONSTRUCTION LENDING AGENCY
y
[. )hereby afnrm that mart is amostruction lendingageocy for me performanceaf
fY,> me work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
z Lender's Address
U0 I certify,mat I be.mad anis application and sum des the tome Informed.I. .
0. coma 1 agree to comply with all city and County eminences And stsu Jim relating in
p bending construction,and hereby,mbonm repoemmadw of mt&city m enter upon and
Gk7 above-mentionAd p ny fo iespection purpuma.
(We),gre ve,indemni(Y anO keep hatmlw me City of Cullom a4lut
V1 IIeb11i0es,Judgto au and expeA_which they in any wey,ttme agalnml said City
O'1 App
or renting of thi.permit.
F7 APPLICANT UND ST SAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE Ju ULA 5.
Re-roofs
Signuure"(Applimof , Dau
HAZA DOUSMATERIALSDISCLOSURE Type of Roof
Will The applicant or future building occupant atom or handle hass thews materiel
As defined by the Cupertino Municipal Code,Chapter 9.12.and me Health and Safety
A.Sccfion 25532(a)7 �a All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future building wcupem on equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
A huatJous air contaminants u defined by me Bay Area Air Quality Management all new materials for inspection.
District]
❑Yes 1 rvu
Ih mWLhehuardwsmmrl,bmquimmenuunderChapmrd95oftMCalifor
niaHcalm S ctyc"de.Swd=2M5.25533u 255N.lund ftifmc Wilding
does nal cu ly Mw•anent,that it u my reasonability m notify fir=Open,of me
scot '7ncnt ie os' met aro Wuanwofa CeNrtesmor Ocedpumy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner mod' egcnt Date