04050156 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CeONTRACTORINFORMATION:
BUILDING ADDRESS: PERMIT NOO 4 0 5 0 15 6
7607 NORMMDY WY
OWNER'S NAME: PERMIT ISSUE DATE
RAY CHEN
WNE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIECI PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION O O O O
AAI hereby affirm that I am licensed under previsions of Chapter 9(commencing Job Description
with Section 7(Ifkr)of Division 3 of don Rev.and Profession,Code.and my license is
^�Nbfall roma and effect. ADD 887 SQ. FT. /GARAGE 450 SQ. FT.
,tg, Limoe Class Lie.,
��p Dam Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he sed as public necMds
�yU
3 LLo G
Licensed Professional
3
OWNER-BUILDER DECLARATION
E<S hereby affirm that 1 1. Bumps Prem he Contrtsc Co :Any c Law for the
pO following mason.Permit
7o I.S. t.alter. and ve demolish.
e low Code:Any city m uctum
i�_ which its requires a permit re cnnswm,alms Improve demhlL h,m e Pair any ommure
Priorbits ce.sil palwrequires theapplicamibe C.hmrmitm files LAO, summcm
that me limn ed pSwtiouotlmpmviaioazafamx,mesasiandcahelaw(C ude)ur Sq.Ft. Floor Area Valuation
(est he is exempt SeaiornAnd of Diasisfrofthc BusinessaM ProfessionsCMc)tar
that he i,exempt mem0om and dm basis for the Jicged cxempaon.Any viohdon hf
Section 703 LS by any applicant for a permit subjects the applicam m a civil penalty of 3 6eN1]16r&et0 0 Occupancy Type
MA,mom man fiK handled dollar,(SX(f). PanC Y YP
❑i,az own¢of de psopeny,m my cmployar wim wage az Nark sole campcnssdon,
will do the work,and meswmum is not intended m offered fhrsalc(Sec.7044,Business ,,,aaa
and Professions l&or The Contractor's and
Law dors not apply lf an owner is RegUlre�in ecttons
.A
Frequent,who b,p.i&ddon such reon.andwho Amsauchwmkh.fr,.delfor through his
own emplayvs,Orevided mos such imps=to within
arc nos intended d mplewn,far sale.r,
however.the building orImpmsermntissold didnoneyearofimpovefrmeowner-
buildm will hove me hardest of proving mal be did net bold hr improve for puryoe of
�4
�$A,taz owner of de property.am exclusively contesting Co licensedThe
Cconrmmors m h
eerie cl me doec.s
(Sec.nanownei of and ny who
Cade:)71st Contractor's Li- "Niwho contracts law does not apply c ah mynas of prepeny who builds os improves Coman.and 00�
whoneeLfor such prejcros with a conuacmRs)limned pursuant so me ConuacmM1
License Law.
❑I am exempt antler Sec. p ,B&P C for mis(rtyason
' her
WORKER'S COMPENSATION DE�ION
1 hereby affnm under penalty of perjury one of the following dechrelions:
1 hive and will maintain a Certificate of Conant to self-intim for WorkersCompen-
suuon,az provided for by Section 3700 of the tabor Code,for the performawo of the
work for which No Permit is issued.
❑1 have and will maintain Workers Compensation Insurance,az required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Imonnce carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thieaceuon wed not bo cmnp:mcd firths permit is for one hundred dollans(910()
or los.)
1-Mly Wt in Ne performance of Ne work for which mis Permit is issued.I shall nm
employ any person in any mannerso az As become subject to me WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making mis Ccnificam of Exemption,you should
become subject m the Worker's ChmP(m a110n provisions of the tabor Code,you most
.,O fhMwith comply with such provisions or this permit shall the deemed revoked.
zed CONSTRUCTION LENDING AGENCY
E" I hereby affirm that mem is a cohswctinn lending agency for tie serformanco of
0: the work for which this posand u ieswd(Sec.3097.Civ.C.)
1 Q I.cnder,Name
z Lender's Address
V 0 1 cenify that I have read this application and all mat the above information is
U.t" correct I agree to comply with all city and county onlinamcs and rete laws lelasing to
Q V building commuclion.and hereby eulsome MOMUnutiKS of this city in cner upon the
rZ
above-mentioned prothe grty outing
inspection this permit. es. I
CL (We)agree to UK.indemnify and keep harmless the City of Cupertino against
o-F.t rA
liabilities,judgments.color and expenses which may in any way acetic against said City
C.7z in APPLICANT
of UNDERSTANDS
ormisDWI
^ APPLICANT UNDERSTANDS AND WILL COMPLY WIALL NON-POINT Issued by: Date
URCE GULATIONS. a
igmm of Applicam/Cemmcmr atc1/ �-Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will use applicant or A.m.building mcupama.Or handl,hoses¢.s mamritl
as deRwd by the,Cupenino Municipal Code.Clupmr 9.13.and dro Health and Safety
Colo.Seetien 25533(a)7
0y. All roofs shall be inspected prior to any roofing material being installed.
Iii Na
T If a roof is installed without first obtainingan inspection,I agree to remove
Will me applicant or future building by the Bt y Aequipment or devices which p
.. itict? m air contaminants az dcswJ by ma Bay Arca Air Quality Managcmcns all new materials for inspection.
District? '�"
(]Yes Ip��((yvu
I he.reel me hosanin-i mamrials aquircmcnu under ChaPmr 6.95 or me Califon
nicellcalmd:Safety Codc.Smumu 25505.25533 low 25534.1 understood theifine building
does ws cwremly haw a(mono Nat is u my responsibility an notify rte mcupant of the
requimmentsw 'ch mug he met prior m issuamc Of.Coruscate of Qcu Signature of Applicant Dale
Owncr or amhorizcd agent DA I All roof coverings to be Class "B" or better