04090296 1 ti, CITY OF CUPERTINO - - _•
fp7N"T,yBUILDING DIVISION � d Z ` Q
`. ._.
BUILDING ADDRESS: - PERMIT N004090296
20395
OWNER'S NAME: PERMITISRUEDATE
DR. JI-EUN HSU
E:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: - - - BUILDING PERMIT INFO '
E B MECH
0
�0o LICENSED CONTRACTOR'S DECLARATION bDeS p y
2
MU ^ 1 hereby affirm that 1'.am licensed eager provisions of Chapmr 9(commencing .- lob -- - - -
F o cn ho _
_ s with Sccurn]IX1Uj of Division7of the Busirrw and Profeuiou Code.end myliceram is _. -�� -""' _ _ _
e „ infullmrceadmfea TI--DOCTOR"OFFICE NOV ]O 2004
jfaz Liceuc Claw Lk.as
Dam Commuter
ARCHITECTS DECLARATION
n 1qq- _ _- ..
�a lundcmland my Phna shall he mcdaspuhlic wind, ', _r- � w - -- -�--��
s t tr Licensed Profession -Ual . -•. .. _• I L®I■ ® v
S OWNER-BUILDER DECLARATION """"-' - '
e1 May alrmm that 1 am exempt from the Conlmaors License Law for the
p0 following muon.(Section7031.5,Business and Profession Code:Any city or county
:m 2 which¢quires a parol,In construct.alter improve,demolish,or rep or any slnrcam
prior ha is issuance,also mquima the applicant for such Permit to file a signed smmment
SSG that he is licensed pursuant to the provision of the Comracmr's License Law(Chapter 9 Sq.Ft. Floor Area ValUHC100
m 1-� (commencing with Section 7")of Division 3 of the Rusineu and Profcssiou Cow)or
`i Nat he is exemptthemfmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of. er0 0 Occupancy Type
nal team Nan five being dollars($500).
O l,uowarofN pmpeny.mmyemploycuwithwagesutheirmlecompenulion,
will do fee work,and the structure is notintended affiliated forsale(Sec.76x4,Business _
and Profusions Code:The Con eselor's Liceue Law docs not apply to an owner of - - -- - Required Inspections
Property who Wildscrimp rra s thereon,and whodoesnch work himeelfor through his ..... ..
own employees,providad that such impmwmena arc not intended w Gffemd for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving thin he did not build or improve for purpose of -
saw.).
Ae.a ties of thm e property,aexclusively contracting with licensed contractors to
nowstmct the pmject(Sec.7044,Business and Profusion Code:)The Contractors Li. t
cone Law docs not apply in an owner of property who builds or improves thereon,and. - -• -who contracts for such pmjeca with a con owtor(s)licensed pursuant o Ne ContrwWr`3
License Law. - - -`•
❑I am exempt under See. ,B&PCfor is o
Owtt� -Da@
WO OMPENSATION DECLARATION'
ni
Ihercby elRtm ndu pcnaltyaf perjury one of the following dal lion
haw and will meinaina Cenifiute of Ceasent to self insure for Workneicompen- ..
sell..,as provided for by Section 3700 of the Labor.Code,fm the performance of the
work for which this permit is issued. -'
❑I have and will maintain Worker's Compensation Insurance,as mquimd by Schon
3700 of the Labor Code,for the performana of the work forwhich this permit is issued.
My Worker's Compensation Insurance carrier and Policy number em:
Cama: Policy No: ,
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This secllan simd not be completed if the permit is tarn,hundred dollen($ILO)
or less.) ... _. _ . .
1 certify that in the performance of the work for which this patent is issued,l shall not
employ anyperson in any manner so as to become subject In the Workers'Compensation
Laws of California.Dam -
Applicant -
NOTICE TO APPLICANT:If.after making this Cardinale of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
Q z forthwith comply with such pmvisims If this permit shall k deemed revoked.
z.,O CONSTRUCTION LENDING AGENCY
F+� I hereby affirm that then is a construction lending agency for the performance of
Cli> the work fur which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name
a z Lender's Address
U Q 1 certify that I have mad this application and stem that the above information is '
IL F correct.I agree to comply with all city ud county ordinances and saw laws relating to
0 building construction,and hemby auNorim represenatias of this city to enter upon the
>i a shove-mentioned property for inspection purposes.
(W)egme m sue,indemnify end keep harmless the City of Cupertino against
nFw 4 liabilidejs, udgmena.costs and expenses which may in any way and,against said City
U'� in conseque...f the grating of this permit. - _
r'•^ APPLICANT UNDERSTANDS ANq.WV 1L COMPLY W,TH AL-_' N-POINT Issued by: D8C
SOURCE REGULATIONS. // ..
qr
i d Re-roofs
`�Signewrc of Applic HAZARDOUS MATERIALS DISCLOSURE De Type of Roof
Will the applicant or future building occupant store or handle haurdous maarial
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
code,soy 25532(a)?es A No All roofs shall be inspected prior to any roofing material being installed.
Will the appfiaant or foram building occupant vine equipment a devices whish .-If a roof is installed without first obtaining an inspection,I agree to remove• -
t hmardow air conaminana as defined by the Bay Ana Air Quality Management all new materials for inspection. . -
istriell
F1 yea �No
I have mad thc huadma materials mquiromenu under Chapter 6.95 of the Califor-
me Health&SsfayCodc.Sections 25505.25533 and!25534.I withstand the ifthe building -
does not currently haw a wast,l t is my,maponihiliry m truly thc occupant of the -
requiremc_ nvvyhichmuubeme, to "amofaCadficaaofOcup. Signature of Applicant : Date
1 6
Owner or authorized aFant ,w All roof coverings to be Class "B"or better