05010154 CI TY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR-, NFORMATION.
BUIL DING ADDRESS: ROBIN .CLUNG PERMIT N005010154
ER's NAME. PERMIT ISSUE DATE
S V
ONE: SANITARY NO. CONTROL NO,
(408) 257-1827
ARCHnECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
W O LICENSED CONTRACTOR'S DECLARATION Job Descri yon O x6" O O O
1 hereby affirm Thal l am licensed under provisions of CWWer 9(commencing p
i with Smfion7q )of DiAsion3ofthe Busineuand Nofesdou Code andmylicrmeis xp`e.,!c
'ray in mummdane mt. REMODEL BATHRM & KITCHEN
5 n? License CIA C Lie,g
Conmcmr n un n
ARCHITECTS DECLARATION
ATION E�'l 2�1�5
I understand my Psalm sWII be used u public records
Licensed Pmfcssional rr�, gggg ,
3 OWNER-BUILDER DECLARATION 1111 p Y n
f I hereby affirm Nal 1 am exempt from the Convector's License Law for IM ELi 6 "
_p o. following mawn.(Section 7131.5,Business and Professlum Cade:Any city or county
$w which requires a permit to ennstmct,10W,improve,demolish,or repair any structure
F ZIa� prior to its lEumcc.also¢qulreS use applicant for such permit to file a signed statement
that he is liccesed pumant to the provisions of the Connector's License Law(Chapre,9 Sq.Ft. Floor Area Valuation
X
(commencing with Section 7000)of Division 3 of the Business and Professiolu Code)or
— Wt be is exempt therefrom and dte basis for the alleged axrmptioa Any violation of
nota start by any applicant fora permit wbjecu the applicant to a civil penalty of 3 660IIII'Q1 crO 0 Occupancy
not am thw Rm hundred dollars for.per p y Type
❑L u owner of the property,army employe;with wages as dub wIc compensation.
wdl Pr Newort endo: s Cmabme,Lt ded craw dors mtApplyto Owner
mrd mywh au cam:711e mMemon,and
law do;cot Apply lf rt owner ar Required Inspections
pwn,ar who buildsor ed dards thereon.and who me;tach work himselfed fersak his
ownemployes,provided Improsneh vement
old Witartnotintendedmpledmd fm own If.
builder,didbuildingordertof ovinistolewithin one year ofcompletion,theowner-
SAM.). will have the burden of proving that be did not build or improv for purpose of
SAM.).
❑1.as owner of Ne property am exclusively with liconud convectors to
contract the project(Sec.7014,Business and Professions Code:)Th.Commissars U.
come law docs not apply m an owner of property who builds or improv;thereon and
who contracts for such projects with a contractor(s)licensed pursuant to the Commences
License law.
El I am exempt under See. ,B k P C for this mason
137Mat Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pevhY of perjury case of Ne following mclamtioas:
have and will maintain aCer ifcme of Consent to self in u e for Worker's Compere
n,as Provided fm by Section 3700 of die labor Code.for the performance of an
for which this permit is issued.
stave W will maintain Wohels CompenSauan I...u required by Section
of Ne Lahor Cam,for thc performance alum work for which this permit is issued.
Workers Compensation Insurance Carrier and Policy number art:
Carrier. Policy No.: ---
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W comPlepd if thd permit 6 foram hundred dollars(SIM)
or kss)
I certify that in the perfomanec of mm walk Tor which this Permit 6 issued,I Nall nil
em play any ponan.many At bjca to the W ftW CMr Munn
Laws of Calf D
Applicant �a�l�T S 34/'d/4
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject Id the Worker's Compenmtion provisions of the labor Coda you most
.J,Z forthwith comply with such provitlons W this permit shall be deemed revoked.
OCONSTRUCTION LENDING AGENCY
I hereby alBm that Vert is a construction lending agency for the performance of
W'7 the work for which this pemtil is issued(Sec.3097,Civ.C.)
1 0 Lenders Name
M z Lenders Address %
TJ Q 1 certify that 1 have read this application yW foto that the above ws Mission u
O U COMM I agree to comply with all city nr county oNt m or and cute laws relating to !
OU buile-minncwctiroand hereby authoredrtpresenmurxsofthis city tocnpr upon Me
shove-menudg a properly for inspection Which A
(ri y (We)agree to Save,indemnify and keep harmless Ne City of Cupertino against
U z incoiti;uence cnts,c;tswdof Unix;permit. may in any way accrue agaiosl Said City ' ,I O�
m consequence of dm Brsnting of this permit.APPLICA� (_
SOURCED- UND NS ND WILL COMPLY WITH ALL NON-POINT Issued by:s4to,6� Date
gel /I 7 a�
siamtu,cofApplican a on Date Re-roofs
I R S ATERIAIS DISCLOSURE Type of Roof
Will the applicant or fumrt uildin6 ecru. ;ort or handle hararmus material
u defined by the Cupertino Municipal Com.Chapter 9.13.and thc Health and Safety
.Section 155321,)?
❑Yat All roofs shall be inspected prior to any roofing material being installed.
Will the applicam or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit M1,vardous air contaminants u defined by the Bay Ar;Air Quality Management
Dirntat? all new materials for inspection.
❑Yes 12INo
V
I have mad the huardtms castanets requirements under Chapter 6.95 of the Cattle,
niaH;lthk$afctyCotic`,Secu 13505.15533vu175534.IondcmmM ifthcbuilding
doe(Ips e _ y no.
ml. el 116 my Rrpamllltltly b natily Nc 0.SupNt of the
mqui n th III MKKprior nissuancoafa C.Mres, foccup
aT�7 os— Signature of Applicant Date
Owner or authorized agent D,m All roof coverings to be Class'B"or better