04030141 FCi]TY OF CUPERTINO '"-_ +*' =
BUILDING DIVISION PERMIT CON'I'RACTORINFOBMATIO N
agyn- r .r
DING ADDRESS: PERMIT NO04030141 4030141
( •
ER'S NAME: PERMIT ISSUE DATE
JIH-PING PE
NE: SANITARY 440. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sao LICENSED CONTRACTOR'S DECLARATION O
1 Wreby"m that I am litttned under provisiau of Chapter 9(Commencing Job Description M3
with Student MB of Divisions 3 of the Business am Professions Code,and my license is
^� infaumeea em.v � 7 /220 ADD 289 SQ. FT. JUL U 2004
A'�zD, nnClas canMUEs�Qr� ' CONTRACTOR: SHACORP GROUP
1 understand my Plans hall be usedS Du ptolic record
)t Licensed Professional BUILDING
OWNER-BUILDER DECLARATION
I I hereby alarm hal I am exempt from the Conamooes License Law for he
oO fallowing...a.(Said..1B3LS,Business end Professinu Code:Any city or county
$ which requires a Permit m convect,alter,improve.ommlim.or at my struch re
F�m< pdorm its issue=,alto requires lW applicant rorsuch Permit 10 rile a signed statement
yF� het he is licenced pursuant m he provisimunfhc Contrecmr'e License Law(Chapter 9 Sq. Ft.Floor Area ValusupR0 0
y (commencing with Section 7M)of Division 3 of he Businessmd Profutions Code)tar
slut be is exempt therefore and he basis fm the alleged exemption.My violation of
Secdon7031.5 by any applicant for a Permit ubjects the applkuuo a civil penalty of APN Number Occupancy e
not mom this five hundred dollars($300). P Y�'P
❑I,asowner ofthe property,cemyemployees with wages As Iheirsele corFensedon, 36913013 . 00
will do me.&-end de ordure is not ism ood tar offered forsale(Sec.1044,Busimss
and Proressm.Cmc:The Contractor'.License Law d.as no,apply in an awror of Required Inspections
property who buildsorimp roan,themorn.and whodoessuch work himseelforthrough his
own employau,provided th n swh improvereenuaw nminu m til oroffered forme It.
however.he building or improvement is Cold within oro you of Completion,the owner.
builder will have,the Wrden of proving that he did mi Wild or Improve for purpose of
tile.).
❑1,as owner of me property,am exclusively contracting with licensed contractre an
coastruct he project(Sec.7(aM.Business and Professions Coe:)The Conuacmrs Lt.
cense Law dote not apply in an owner of property who Wilde or improves hereon.And.
who Cornea,for such projects wire s comosever(q licensed pursuant in res Comammes
License Law.
1037'yl
amexomptunderSec ,BkPCfarmismuaner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of he following declaratlons:
have end will maintain a Certificate of Consentto self-iuun for workers Comperen,u provided for by Section 3100 of he labor Cme,for the performance of he
for which this permit is issued.
have end will maintain Warkcrs Compenutian luumce,u rtyuimd by Section
of Me Labor Code,for the performance.(he work for which this permit is issued,
Workers Compensation Insurance carrier and Policy number are:
er. �o4�C Z'vaJsJ~Poicy N.J
ERTIFICATE OF E%EM TON MWORKERS'
COMPENSATION INSURANCE
Obusecu.n need not uncompleted If tle iemtit is foram hundred dollan(SIIXI)
or leu.)
I cenify met in the performance of me.,it for which this permit is issued.I shell am
employ any person in any manner an as to become object o the Workon'Compensation
Lawa of Califomia.Dam
Applicant
NOTICE TO APPLICANT.If,after making his Certificate of Exemption,you should
become subject m the Worker's Compmnation provisions of the labor Cmc,you mut
.`z foMwim comply with such provisions at this permit shall he deemed remked.
ztO CONSTRUCTION LENDING AGENCY
[-�� Ihereby affirm that here is a construction lending agency for me perfurmance of
C
the work for which this permit Is issued(Sec.3091,Ci,C.)
QLendcr's None
Z z Landers Add.
IS,Q Ittnee the Iham rodthis
ty ad ounandsussthe he sumiwsmintuun to
Br building
I agree to comply construction.and wire all city and county ntatnanas and cum laws rclaung m
0 bWi C-nmmmmandhembyemhon percpruemauws of this city to enter upon dte
(A aWv>menuancd propcny for inspection pugwxa
gy (Wc)agree to ssve,indemnify and keep harmless the City of Cupertino against
ver rA lihlliticalumcml' s nuewhich may in my way accede Against old City /s
V 7 A APPLICANT
of he gaming of is permit /
F7 APPLICANT UNDER A LL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION zy"
° Re-roofs
SJ' net ltcanl/Canu for em
0 IALS DISCLOSURE--. Type of Roof
Will the applicant or future Wilding Occupant smrc or handle huardous material
an, by de Cupertino Muni'Pel Code,ChaPmr 9.Iz,and res Ncalh end Safety
.Score 255P(a)? All roofs shall be inspected prior to any roofing material being installed.
❑rte o
Will the applicant a fum Wilding Occupant use equipment m dcAms which If a roof is installed without first obtaining an inspection,I agree to remove
mit toenail air cmumaranu u de0ncd by the Bay Arta Air Quality Managemcul all new materials for inspection.
DistricR A
❑Yes�—��N'
Iham rem he huam m` 'ala mquiremcnu under ChaPter6.95 afIW Califon
nia Healre&safctyCmc.scni S.g_- lul u115S3.lumrsu ouifthc Wilding
dos rot c dy hew cit het u my respmuihility m notify de attupantalent
regain u . metptlarn.mm.ncee,marc.pj C� Signature of Applicant Date
D T
Owner a, Date All roof coverings to be Class "B"or better