02100001 CITY OF CUPEKI'INO "' "T" I
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Bulll)60,4111-ORANGE AV ITRMITN®2100001
OwSF19NGWCHIH-HUA G AND SHWU-KUAq APPLICATIpUl/Us1T1+2002
ah
IFIONII. SANITARY NO.// / CONTROL NO.
ARCI IITECIENGINEER: BUILDING PERMIT INPO
BLDG ELECT PLUMB Mmil
woo LICENSED CONTRACTOR'S DECLARATION O O O O
K U F 1 III mltirm that I am licensed under provisions of Chapter 9(uimmemcing eS r [I
C« withSectionvskBofDlvksbmlottheBasin.xxandPamssiomColle. Jmylicenseia TUB SURROUND/'ICY r(� BATHS)
in fulllotVe f G!3 O
�n Z hicen-C hoe
2o„-o Date Gltm / FINALED
—yC'o'il ARCIInECI'S ARAT N Ft
C K� 1 understand my plans shall be used as public areards
doaU
dog
Licensedprofexximna' MAY 1 4 200
OWNER-BUILDER DECLARATION
1 hereby infirm that 1 am cu=min from The Comm=on,Lleensc Law for he
$950
ce S 00 following reason.(Section 7031.5,Business and Professions Cale:Any city or county
X S� which re4uines a permit tar construct,alter,improve.demolish,or repair any.someone
rot` prior to its issuance.also requires the applicant lor.such permit file a signed statement
�i< that he is licensed Pensuanuo the provisions of the Contramnr'x License Law lChapner9 35-g713t.4I »tAl@8BUILD On
&FG (commencing with Section Ask))of Division 3 of the Business and Proferouns Code)in
to that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Senium 7031.5 by any applicant for a permit subjects the applicant m a civil penmty ofPN*N Occupancy Type
not more man True hundred dollars fssm). 102 — PIERS
Fl 1,as owner of the property,or my employees with wages as their sole compensation,
will do the wmrk,and Ne aweture is non intended or offered for sale(See.7W.Business
and Professions Code:The Commodes License Use does not apply to in uwnet of 104 - REBAR Required Inspections
moiety who builds or nannies themmn,and who does such work himself nr through his
ownemploycn.provided that¢ucM1 improvements am not intended mroffered for side If. 105 — ANCHOR BOLTS
however,the building tar offoreemem is sold within one year ofcmmpledmn.the owner. 106 — SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
xale) 202 — UNDERFLOOR PLUMBING
CD 1,as owner of the property,am exclusively contracting with licensed conpacmor m 2 03 - UNDERFLOOR MECHANICAL
cnnswct th=project(Sec.70,14.Business and Professions Code:)The Contractors Li
crime law does not pply no an owner of properly who builds or improves thereon,and 204 — UNDERFLOOR FRAME
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor':'
License Law. 205 — UNDERFLOOR INSULATION
❑ I am exempt under Sce. ,B&P C for this..,in 301 — ROUGH PLUMBING
Owner Date 302 — TUB & OR SHOWER
WORKER'S COMP12NSATION DECLARATION 303 — ROUGH MECHANICAL
I hereby alum under penalty of perjury one of me following declarations: 304 — ROUGH ELECTRICAL
1 have and will maintain a Certificate of Consent to siff-r sum for Worker's Counter.
saimn,as provided for by Section 3100 of the labor Code.for me Performance of the 305 — FRAME
wmkfotwhichthispermiti,emcd. 306 — HOLDOWNS
1 have and will maintain Worker's Compensation Iosmance,as reyuimd by Section 307 — INSULATION
3101 of be labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation lnscomec mrrier and Policy number me 308 — SHEETROCK
C 'c STC FI ATE Policy No.:
Z 309 - EXTERIOR LATH
CERTIPICATIi OP EXEMPT F WORKIiRS'
COMPENSATION IN NCE 310 - INTERIOR LATH
(This section need not he completed iftM pertain is Intone hundred dollars klOB 311 - SCRATCH COAT
or less.) 313 — ROOF NAIL
I cenify that in the performance of the work for which this Permit is issued.I adult not 501 - FINAL ELECTRICAL ENERGY
employ any Person in any manner set as to become.mbjecno the Workeri Compensation
LawsofcaufoniaDate 502 — FINAL PLUMBING ENERGY
Applicata
NOTICE TO APPLICANT:IL after making this Cereficam of Exemption,youshuulJ 503 — FINAL MECHANICAL ENERGY
become smbjecno he Workers Compensation proeifenxol he wbor Code,you mast 504 — FINAL BUILDING ENERGY
,Z, forthwith comply with such provisions or this Permit shall he deemed revoked.
0
z 0 CONSTRUCTION LENDING AGENCY505 — FINAL ELECTRICAL
P In ;cncy
Thereby affirm that is lending reg=^=y for the Pcrlisrmanee of 506 — GAS TEST
a > the work for wInch this Permit isissued(Sec.NAD,Civ,C.) 507 - FINAL PLUMBING
❑] n Under'
ende's AJdsAdrm 508 — FINAL MECHANICAL
7Z LcndcrAddress
U O 1 cenify man 1 have read this application and stale that the above intonational is 509 — FINAL GRADE
F correct.l agree to comply with all city and county ordinances and state laws relating no 1
UU building construction.and hereby authorize representatives of this city no enter ulant the 5 FINAL PLANNING
r W aMwc.mentionedpropenyfor inspection purposes. 14 FIN I WIRKS
(We)agree w save,indent ,ly and keep harmlusv one City of Culwnmo against
tiH liabilines.ludgmants.casks and expenses which ayinany y accrue igmair said City
U Z to consequence of the gra if (this pe it.
�+ APPL1 l'UNDERS N S ,1.COM WITH ALL N N-P INT Issued by: Date i
S CE !GULATIO S /
11 Re-roofs
o Applican o” Una
IIAZARAZARDOUS MATERIALS tsSCl.0 RE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by one Cupertino Munici al Code,Chapter 9.12,and the Health and Safety
Ode.Section 25532(a)1 All roofs shall be inspected prior to any rooting material being installed.
❑Yes No
will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
an in haeardous xis conmminants to ted by the Bay Area Air Quality Management all new materials for inspection.
Duarte
❑Ycx No
1 have read me hazardous materials requirements under Chapter fi 95 of the Califor-
nia Ileulth&Safety Code.Sec tions 25505,25533 and 2553 1 un l voranl On if the building
tires nm c ly base a tecta nom itis my, r ty to notify nM cup.,sl the
uses 02 lenntost Ip mm m reons e 'fi=amorlxepp =x Signa[urcofApplicant
Date
All roof coverings to be Class "B" or better
ncJ aI ID m