04050104 CITY OF CUP
ERT INO ^y' m� zrsx., �.
BUILDING DIVISION PERMIT CONTRACT®R INFORMATIONI
BUILDING ADDRESS: KIM' S CUSTOMER BUILDER PERMIT"°04050104
OWNER'S NAME: PERMIT MUE DATE
AML SUNG SOO PARK 22714 AT,rAT.DR RD 12R19on4
NE: SANITARY NO. CONTROL NO.
408 999-033
A CHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� I� (�
°00 LICENSED CONTRACTOR DECLARATION Job Description
w 1 hereby affirm that I am limnscd under provenqPsof Chapter 9(commencing p
ip� with lon]Q10)a(Division 3af sew Busineu,/erldf��`a'Tdssr,oto Codaand my license is
,qi morn _a�..��y��� Lic.g r ` i �U ADD 1000 SQ. FT. /REMODEL
`� oawconvawr (3 BEDRM/2 BATHRM)
4 I( ' la ARCHITECTS ON
a' 1 undc Ian my plans¢hell u blit mmrds
;Oti LiccrucO Pmfcssional
OWNER natio f DECLARATION
2 f I Wmhy affirm that 11. ,Boor from the fco uactCo l:Anyc Law for the
n O which mx reason.(Snout]031.5.Business and Profneludi Cod,:Any city or county
m ff which myuirts issuance,permit re�ms t e pplic,improsu,demolish,ore Pair any awttum
�� prior Inslts ensedpalsontto the theapplicantof for such Patois ie ssigncusuwmem
(comma cccnud Pursuant m the of Division 3 dr,Contractorsnd Professions
(Chapter 9 Sq.Ft. Floor Area ® Va l£"IC JJ000
s.
(commencing is;exempth Section]0nd of basis
rth the
eged exempt on.Any
Code)or
.i�9 uses h<u comps thertfrom and the baso far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than BK hundred doll.4500). 36216034 . 00 ✓ p y YP
0 1,u ownu of she property,n my employed with wages u their sole compcnuuon.
will do the work,and ole aNwwre is not intended oroffered for sale(Sec.70,l,Business 1
and Pmfwioru Code:The Conuumrs Liceve law dao not apply N an owner of '' �InS 'tions
.employ builds orimprovu thereon,and who daessucM1 wmkhimulforNrough his O
howemployus,providednprovehimproold will
forsala IL
builder.the building order of pmensisoldwithinone year of completion.purpose
owner- (/
builder will M1aw the Carden of proving that W did not Wild or improv for puryue of
ole.).
1.ai owner of the property,am exclusively contracting wish licensed com oscbra to
comwcs the,project(Sec.7044,Business and Professions Cade:)The Contractors Li. ,r
roue law doss not apply to an owner of property who Wilda or improves Merton,and
who contracts for such projects with a comosee r(s)licensed pursuant to the Consumers
License law.
0 1 am exempt under Sec. ,B A,P C for this reason
Owner Data �— -
WORKER'S COMPENSATION DECLARATION
1 bcmby aRmi under penalty of perjury one of use following declarations:
I have and will maintain a Cerofcme of Couem In ulbiuum for Wa sseh Campem
ion,as provided for by Section 3700 of the Labor Code,for the performance of the
orfor which thin permit isiuucd.
0 t
1 have and will maintain Worker's couauan I k f'wh,as his Per by Section
]]00 of Ne Later Code,for the perform a of the work for whicM1 than permit is iuucd.
My Workers ompghsauon teal 'nand Policynumbcrarm
Ca 'e Inti ti Policy No.: S b
CERTIFICATE OF EK MON FROM ORKE S'
COMPENSATION IN E
(Thu s ctian nccd of W completed if sec permit is foron,hundred dollars(SIM)
or less)
I oto fy that in the performance of the work for which this Permit is issued.I shall not
employ any portion in any mannerso as In breome subject to the Warkcrs'Compensation
Laws of California Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become sub*(to the Workers Compensation provisions of the Labor Coda you mum
.J 2, forthwith comply with such Provisions or this Permit shall W deemed revoked.
'ZO CONSTRUCTION LENDING AGENCY
Fw' Ihereby affirm Wt Nem is a construction lending agency far the perlurmanls of
ai the work(ser which this permit is issued Sec.3097.Civ.C.)
[gl 0 Lenders Name
6. Lender's Add. -
V C I xNfy that I low read this application W sow Nat the show infmmatiun iscem —
t" building
I agree el comply with all uth and county oNirWwof and claw laws r upon
s,
C V building cowmuiro.end for by inspech......esenlativrs of this city mcnwr uPan the
1 ahovomenuoned Property for abler as which Ma
(We)agree to sass,indemnify and keep harmless the City of Cupertino against
IF-I Z incoiue;junceofb,canuantl expemawhicM1 may in any way accrue against Said City
t)z in corvequcnce of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: D'
SOURC REGUL TIO
Re-roofs
S roofApplican to ¢w
HAZARDOUS MATERIALS CLOSU E Type of Roof
Will see applinnl or future Wil ' gncupant mom or Wrule hazardous material f
de,0ond by thin Cupeniao Muni' al Code.LTaNer 9.12,and do Hca IN and Safcsy
Code.Section 25532(a)?
D Yes
Na All roofs shall be inspected prior to any roofing material being installed.
W01 thea applicant mwrc b If a roof is installed without first obtaining an inspection,I agree to remove
Pp ing accupam tau cyuipmcm art securest which g p
amu bavasdo.,air cmuemi cols erred by Nee Bay Arta Air Qaarly Management all new materials for inspection.
District?
❑Yes No
I haw read the hang ousonven lartyuirements under Chapter 6.95 or the Califon
tie Hcslth d:Safcty Code,Se thou 25505,25533 and 25534.1 undcrswnd mart rich,Wilding -
does not current law
a mnan4 than it is my responsibility m nobly the occupant of Nee
myuirtmc i ."hem'lpriorwiuuume,!�c f¢aw &Cu cy. Signature of Applicant Date
Owner ar,nth...d ager Dam f All roof coverings to be Class"B"or better