06120048 CITY OF CUPERTINO 'a+- *+I r•+ ` �' '%"� }`
BUILDING DIVISION PERMIT ;.C'�1NTRACTCJRM'OI21'I.4TION
BUILDING ADDRESS: Ig� v PERMIT NO.06120048
OWNER'S NAME: �y.,� PERMIT ISSUE DATE
MICHAEL DONG s%wm me'
E: �Q SANITARY NO. CONTROL NO.
rvNY1n R 5 cA . 9
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EI-ECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
m I haeby affirm that 1 am licensed under provisions of Chapter 9(commencing P
with Section 7")o(Division 3 ofth4 Business and professions Cadeard my licenseis
« in run fame andeffaa ej eg7I KITCHEN REMODEL - NON STRUCTURAL
s"t�? License Clazs Lc.r —
Data1- Convector "I `aSLG
^ ARCHITECTS DECLARATION
i 0i<
: I understand my plans shall M used az public records
yU
°Q� Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby Arline Thal I am exempt(teen the Co men s's License Law for Ne
n o fallowing wasan,(Seedon]18usin
1.5,Bess and Prorrisiom Care:Any city ser county
e m ff which¢ e quira Permit at ca most,alar.improve,demolish,or area,any someture
1xi prior in its issuance.ziau requires de,applicant rot such peonit to fk a signed stsament
-
'hat he is ficantod puresnam to tiot proyisions of the Comaxim's Licars,Law(Chapter 9 Sq.Ft.Floor Area Valuation
ex
`~$ (conamencirig hessian T and hadison 3 dice a sgid e.and Proression.Ar,
Cade)of $20890
-. that W u exempt h.-from and Oa bm8 for Ne alkgcd exemption.My violation of
Section 1031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mare Nan fee handed dollars(MOB0
❑1,as owner of the property m my employ,.with wages.the'ir role campewdon,
will do the work and the swch e u ear intended m aResed for aside(Sec.10x4,Business Required Inspections
and Connector's teinPentad..Cade:The Coctor's License Law circa t apply an owns e ns of q P
Property who Wilds.,improves thereon.and who doe,mchwarkhieaseifar through his
own employes.provided that such improvements are notheardled maffsmal forsobe H.
however.the Wilding or improxemant is sold within ane year of completion,the owner.
builder will have the burden or proving that he did not Wild or improve for purpose of
sale.).
O I,az owner of the pmpeey am uelusively contracting with licensed convectors be
construct doe project(Sec.1044,Business and Prafemians Cade:)The Conmceses U.
emse law da.ma.,,IY be an owner of property who Wilds ser improve thereon and.
who contracts for such projects with a canmacter(s)licensed pursuam to We Camozeures
Lice Law.
❑I oro exempt under See ,B&PC for Nu mean
owner Data
WORKERS COMPENSATION DECLARATION
40 1 hereby&Man order Rnalry o(Rrjmy am of the following dcciamuom:
0I ..dwillmainuina Cersiruamo(Com,nuaulf-imumfmwof SCmnpen-
m ine,as provided far by Section 37W of the Labor Code,for the pedwee eta of one
work for which this permit is isued.
❑1 have and will maintain WMIm'.s Compensation Insurance,as expand by Seeds.
37W of the Labor Code.for the perfmmane.of Ne w.h far which the permit is Issued.
My We, s no'1c�a�adan .,arta ueim ard Poli,��mjamb.�eer are. /
Lamer. oAF `aMQ Polity Nu.IM(2-30 V
CERTIFICATE OF E%EMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Thissection recd not W c mplced if the permit Is foram hundreddellan(3100) ,
or Iasi)
1 artily that in the performance of the work rot which this Permit is issued,I shall not
cmpl.y any person in any sesoncr.az to became subject in the Worken'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.afar making this C,rtifcate or Exemption,Y..should
Income subject to the Workeri Compensation provisions of the Labor Cock.You muse
.J O faMwith comply with such pr.visisns or this Permit shall W dermad revoked.
z ret CONMUC1ON LENDING AGENCY
1-s I Wreby aRmn the Nee iso construction lendingagmey for cite Performance of
ai the work for which this Permit is issued(Sec.3091,Civ.C.)
Iz1 Lender's Name
z Gamices Address
V 0 1 certify drat I have mad this application and state that the about infovnmim is
U. correct.l agree to comply with all city and county constructs;ard sura laws meads,to
V Wileingeonswetinn.and hereby smhmm repmsemmives of this ciry to cover upon the
move ms.judgdpmpcnt ran inspection ptur,owhich s.
H y (We)agree m save,indemnify and keep harmless the City of Cupenina a,ainst
N inconseque consequence
of th.e amend expenses which may in any wayaamc agaimtsaid City
U z A cansegmnce of the granting SNis permit
^ APPL ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale "
SOW9E REGULADOP
_ GZA.� 1 `� f Z -1 L 'a6 Re-roofs
Signature of Appli.nvCortmcter - Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Win the applicant or fuuuc Wilding oceupenueone of handle haamake s material
M defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
cada.Section 25532(anAll roofs shall be inspected prior to any roofing material being installed. -
❑Y. ON.
If a roof is installed without first obtainingan inspection,I a o remove
Will the applicant or future building occupant six cyuipment or devices which � agree t
g '
emit hassedous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
Duvict?
❑Y. 0N
1 have mad be handtws materials requirements under Chapter 6.95 of the Calirm.
Me H.Idt k Safety Code,Section 25505.25533 and 25534.I andereard tlm irtlte Wilding
dos I hoc a amain Nm it is my responsibility to notify the a:cupans of tM
n, �norg)� hmuvbc gqpriartei.a„taafaccrafaaofaeupancy Signature of Applicant Date
_ (,LtJL� �L._� ►'1-1 L^V 6
Owner or auth.rivnd agent Date Ail roof coverings to be Class "B"or better
'