04120110 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .11.CONTRACTOR INF.URMATION ..... - - ._
..�
BUILDING ADDRESS: PERMITN®4 12 0 11 0
607 NORMANDY WY
(1WNER'S NAME: PERMITISSUEDATE
RAY CHEN 12/16/2004
OrNE: - SANITARY NO. CONTROL NO.
ARCHITEC fENGINEM' BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
y O U LICENSED I a CONTsed and RS DECLARATION
of hap Job Description
�uF Ion 7 affirm that 1 am licensed under provision of Chapter 9(commencing p
ZjW with$cction]0(IU)af Diviaian3of the Businw erW Pmfcssioos Code.andmylicersse is
<.„ ofulfomeaodenem REVISION--IN HOUSE USE ONLY
ien5 z los Lin.«
Done NO NEW PERMIT ISSUED/ ORIG. #04050156-
Done.Con - '
££
ARCHITECTS DECLARATION
j W 1 understand my piens shell hm
e used u public rtenr
U
a
3 Licensed Professional
3 OWNER-BUILDER DECLARATION
�f 1 berchy affirm that I am exempt from the Contractors License Law for Its
i 00 following mann.(Section](Bis,Business and Proficeak m Code:Any city or county
X m 9! which requires a Permit to convect,alto,improve,demolish,or repair any swcmreOr
- —
t-zi prior ext its issuance.a4u mquima use applicant for such permit to filo a signed moment -.
ip
that he is licensed pursuant10 the provisions ofthe ComactertLicense Law(Chapter 9 Sq.Ft. Floor Area Valuatio 39
�$ (commencing with Section 7003)of Division J of the Businev and Professions Code)or
that he u exempt theefram and the basis for the alleged exemption.My violation of
Section 7031.5 by arty applicant for a permit subjecu Ne applicant to a civil Penally Of ApN Number
not mom man BK bunded dollars($500). 36611159 . 00
Occupancy Type
❑I,as owner of me property,or my employees with wages u their=to compensation,
will do the work,end 0s structure isnot intended moffered for We(Sec.7014,Business -
aM Pmfessfaru Code:Th.Conaumrs Liause Law docs rat apply in an owOcr of - - -+- Required Inspections '
property who buildsw improves thereon,and who doessuch worlehimselforlbrough his
ownemplayw,pmvidedmalsuehimpmvemcM=a immnds oroff Wfors lf,
however.dee building or improvement is oath within one)car of completion,Ne owner-
builderuilder will have the burden of proving Wt he did not build or improve for purpose of
sale.). C\�
❑I,as owner of the property,,B exclusively continuing with:)The
contractors i.
construct the esproject(Sec.]ad,Business and Py,who hm Code:)Thems ft. .Li.
ewe law data not apply m an owner of Property,who builds or improsss menton,and,
who contracts for such projects with aconuactor(s)licensed pursuant mthe Contractor's
Cleave Law.
❑Lem exempt undo 5ce /' ,B&PCfar this moon
O c �t i1 /ice
D. s'-
e=rg _
WORKERS COMPFNSATIONDN ,-.
1 hereby edition under penalty of perjury Oa of the following declaraziome - - - -
Ihawandwillmaintaina Cenificam of Consent to selDivure for Worker's Compen-
.cation,as provided for by Section 3]00 of the labor Com,for the performance of the
work for which this pconit is issued. - -
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
J]00 of me Ver Code.(or IM performance of Ne wort for whicM1 thispermit m Lssae.
My Workers Compemacon Iran..carrier and Policy number are
Causer. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This moon sad oat Wcompleted if the fermil is i.e.hundred callers(Sim)
or less.)
I certify mot in on,performance of the work for which this Permit or issued,I shall not
employ any person in any msmerm as to become subjen to the Worker)Compcwllon
Laws of California.Date
APplicrm
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shouW
become subject on the Workers Compensation previsions of the Ia1crc Code,you raw
.,O foMwith comply with such provisimu or this Permit shalldomed re
be voked.
Z'y CONS(RUCrIONLENDINGAGENCY
(-+ thereby affirm that then is a eonsmetian lending agency fm the Performance of
ai the work for which this permit is issued(Sec.3099.Ci,C.)
1 Leadars Name
z lander.Address
J C) 1 ceoily that I have rud oris application and sum thn the above information is
IL ^. cortett I Ince to comply wire all city and county oadiumme,and state laws relating Io
C) rl`J building convection,and hereby authorim mpresenurims Of this city to toter upon the
shove-mentioned property for inpeetion Purposes �/`^�/KJV I
F a (We)agree to save,indemnify and keep humorless me City of Cupertino against
rA liabilit einuence
judgmenu,core and esp..which may in any way seethe against said City
t),ZNTof the DERST NSNis Permit.NT UNDERSTANDS AND WILL COMPLY WITH ALL NOIssued b GULATIONS. y' Dateo(ApphcanVCanvacmr Dam Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ur fume building Occupant srm.orhandlc haurdaus matetial
v reflood by tho Cupertino Muer'pal Code.Chapter 9.13,and desHuta and Sa(my
ode. El es 35532(a)? o All roofs shall be inspected prior to any roofing material being installed.
El yes No
Will ter.appliant f building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardnus air conumi v .fined by the Bay Ara Air Quality Management all new materials for inspection.
Dislrin? -
❑Ycs
I have read the by nusmazerialsmquiemenu under Chapter 6.95 of the Calirm.
nice Hcalthg:SaluyCvnce,e.u,movosit My responsibility
undcrsund thmifthc building /�� j/�j0
doe, currentlyie haw a lemnt that it u Myynce onibiliti c na the attvprnt of me e/%%�(!f/H / f
eyu me LwhkhmvtbcmetptiorwissuanccofaCcrtihcateaf Signature of Applicant Date
Uwner or authomcd agentAll roof coverings to be Class "B"or better