04030235 CITY OF CUPERTINO - n '" ' " `•�`
BUILDING DIVISION PERMIT CIONTPAMIkINF , I,tMA'�ION."
BUILDING ADDRESS: PERMITN004030235
1 171977 NnPTT4,qRAT, go
R'S NAMKAY E: PERMIT LSSUB DATE
HEFFER
PHONE: SANITARY OL NO.
ARCHITECDENGINEER: - BUILDING PERMIT INFO
BLDGBI-F.L7 PLUMB MECH
1=1t� l� l�
u o O LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am Iicensed under rovisiona of Chapter 9(commencing Job Deseri [ion -
�� with Seafon70f110.f Di,k%km3.f the Buri ,m, tom Cede,sndmylicenscis RM
ALE®
a8; era roc andcrfecs —II�3y5T KITCHEN & 2 BATHRM REMD�
l Lken ss Wc.p
^Fq gk CanAO V-Vk CONTRACTOR: HAO RUI SITU
ggq❑❑ A0.CN1'IELTSDE I. TION JUN 21 2004
I umdmmtsnd my plain shall W uutl u puMi codes
O
Licensed Prof casionel ,. BUILDING
OWNER-BUILDER DECLARATION
a I hereby affirm on 1 em exempt Goat Ne Canons Car License Law for the
i O O following reason.(Section AD 1.5,Business and Professions Code:Any oily or county
which)in issuance,
s u a Permit In cores the pier.improve,demolish,or repair any muctustatement
FAL' Chior t heist iensdpursu mqn the previsionants
for such pctor's censele a signeddmmmcm
S3$ Ihalhcincanscdpursuantrothcproviviouofthe ofMoBuwmsSWarvclaW(Chepkr9 Sq.Ft.Floor Area Valu I
}E (commencing with Section 70f0)af Divuion]nf the Business and Pmressians Cadc)or Q11J000
Nat he is exempt therefrom and the basis forthe alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nos mart Nan five hundred dollars(Stat)
01.are owner ofthe property.or my employees with wages m thelrmle compensation, 31640011 . 00
willdo the work and deeswnum is not iniended orolTcred I...1.(Sec.7066.Business
and Profeseiou Cade:The Contranrofs Wants:Law does not apply to an owner of Required Inspections
property who Wilds orimprovea thereen,andwho doessuch work himmlrorthrough his
own employees,provided that such improvements are notinu nded oraercA foreak.If.
however,Ne building or improvement is sold within can year ofoompletion.Ne owar-
builder will have the harden of proving Nat W did not build or improve for purpose of
sale.).
1,not owner of the property.am exclusively contracting wide licensed com oscura b
convect the project(See.7064.Business and Profession Code:)The Contractor's Li-
cense law dos not apply in an owner of property who Wilds or improves thereon,and
who contracts for such prejec6 with a contractor(s)licensed pursuant o Ne Contractor's
Ltcone law
.
l amcxcmptunder Sa. ,BkPCfm Ni..on
ter Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following deelsrstions:
I have and will maintain a Certificate of Consent to self-insure(or WorkerYCompen-
ution,as;provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
3700 elf N�Uttar Cada,for the performance,of Ne work far which this permit is issued.
My WVmAa'a Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
Into xenon need no W comple ed lithe Permit I6 furore hundred dollars($1 011)
or Ices.)
I certify Nes in the Performance of the work for which this permit is issued,l shall not
employ any Pcr�onimu nany rssamaStob�omesubjecsm Ne Workcri Compensation
Law s of Calif on a 3 iVy�4
ApPli lit
E TO APPLICANT:If.after Commaking this nisi n s of of Exemption,you should
c emajor,hecomp ro the Worker's Compensation provisions of the Labor Code,you mum
,J{� orNwilh comply with an provisions or this permit shall W deemed revolted. '
ti O CONSTRUCTION LENDING AGENCY
[-t I hereby affirm Net More is a construction lending agency rot the performance of
ai> Ne work for which this permit is issued(Sec.3097.Civ.C.)
W� Q Lender's Name
] z Lender's Address
V Q I certify Nat I have mad this application and sure that the aWvc information is
F correct.1 agree in comply with all city and county ordinances and sate laws minting to
O(J Wilding construction,and hereby wansixe representatives of this city to enter upon dee
W above-mentioned property for inspection purposes.
C (We,)agate to save,indemnify and keep harmless the City of Cupertino against
fA Imbilitiu,judgmenu.comuand expenses which may in anyway accrue against mid City
t„)7 inconsquenceoft antingofthispermit.
F7 APPLICANT STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERE TION
326 CV Re-roofs
44
ign of Pp ea3iVCantrumr Doc
HAZARDOUS MATERIALS DISCLOSURE - Type of Roof
Will Ne applicant err future Wilding occupant store orhandle hamdous material
dcfood by Ne Cupertino Municipal Coda,Chapter 9.12.and to Health and Safety
dc. [3 Y.15531(a)? /\JS�t\No All roofs shall be inspected prior to any roofing material being installed.
Will the applic aams'r future building occupant tsar equipment err denims which If a roof is installed without first obtaining an inspection,I agree to remove
cath ha'rardaus air examinants as dcfncd by the Bay Area Air Quality Management all new materials for inspection.
Diseict? '�I
C]yes
I have mad the W>nrdoys toerials requirements underChapter 6.95oftheCalifor-
niaHcalNkSafctyCodc,SccdoI 25505,25533wd25534.lunl mundthuifthe Wilding
dos not curenlly haw a 4 Nat it is my msponsibiliiy m nodty Ne,occupant of thc
mquircmcnm which mu met pri Kinnon ora enearacup y Signature of Applicant - Date
2(
Owner lir h .d agent Dae All roof coverings to be Class"B" or better