04070084 CITY OF CUPERTINO "k
BUILDING DIVISION PERMIT C�ONTRACTOIA I�NVO tMAT�ION - - - -
BUILDINGADDRESS: """"04070084
19R PATIO VTqTA PT)
M'SNAME: PERMIT ISSUE DATE
DANNY WONG
7ARCEUTECTIENGINEER:
NE:
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSEDCONIRACTOR'SDECLARATIONJobDescri tion
1 Wroby affirm that I am licensed under provisions of Chapter 9(commencing P Section 7")of Division 3 of IW Business and Professions Code.and my license u
uforo andetm ADDITION/REMODEL (B H/ENTRYnse Class -Lia N
Dam conte or 944 ' MATERBEDRM/B
ARCHRECrS DECLARATION
understand myplans aWlbused upublic rtcrrd 08/24/04 ADDRESSw 094 TO 10398
Da`u
CC', Licensed professional
3OWNER-BUILDER DECLARATION CU
F I hereby alarm Nat 1 am exempt from We Contractor's License law for the �I
p O following rounn.(Section 713 L5,Business and Prefacti m,Code:My city nr county I� 1GG
5:0C
$ff which requires a permit to cnnumm,alter,improve,demIdub.or repair any Um boo
prior tat ice issuance,also ro,juna the applicant for such permit m file a signed statement
that he is licensed pursuant in the provisions of We Contractor's Uccnse Law(Chapter 9 Sq.Ft.Floor Valuation
0 (commencing with Section 7")of Division 3 of We Business and Professions Code)ofQU
$ Nat he in exempt Nelfmm and the basis for We alleged Gumption.Any violation ofA Logaiiiii, $180000
Section 7031.5 by any applicant for a pewit subjects We aWlicanuo a civil penalty of APN Number ft-Occupancye
not mol Nan five handled dollar(5500). Type
P
I,mo nuef Nepmpusy,ormyemploya ffiwagcsazdmuxlemmpensadon,
will do the work end Ne swnurt isnotintended oro@Id forauc(Sec.70U,Buumus
and Pmresimas Code:The Commences Lixrurs e Law donot apply m an owner or and Inspections
pmpeny who builds Ids or improves themon,end who does ouch work himself or Ihmugh his
own employees,provided Nat such impronamrnuam not intended orogen l for sale If,
however.We building or improvement issold within one year of cumplevon,the owner-
builder will have We burden of proving Nat x did not Wild or improve for purpose of
.In).
as ownwr of the property,am exclusively contracting with BernarA con ncssrs to
on wet We project(Sec.70ad.Business am Professions Code:)The Countesses Li .
cense law does not apply m an owner of proper wh ilds or improve thcleon,and
who cu for such put acuwithaconuteror(a)li sed purswmwdm Conowun"
Lice w.
❑Iameacm @s See. .B&PC1fo Nis Pa.
(0 (9
am
ORKFR'S CO B ON DEC RA
I h by affum under pc ty of perjury am of (o awing declarations:
IIs wa dwillmainmina enificataof Consent If-maum for Worker's Coat
tion,as provided for by Sermon 3700 of the lab r Code.for the pefformance of We
work for which Nis or is issued.
❑I have and will murnam Workees Compensation Insunnm,az Imputed by Section
3700 of the Labor Codd,for We perforrumm of We work forwhich this pewit is issued.
My Workers Comper onion Insurance carrier and Policy number am:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This action reed notice completed liable permit isformw hundred dollars(SIM)
or less.)
1 certify Nat in We performance of the work for which this pewit is issued.I shall of
employ any person in any mannerx az to become subject o the Workers Cpmpensadnn
laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Cc idical of Exemption,you should
become subject m the Worker's Compewtion previsions of dte Labor Code,you must
,,- O foMwilh comply with such provisions or this remit shall W deemed mound.
Z N CONS RUCnON LENDING AGENCY
[-+ I hereby affirm Nat Net is a construction lending agency for the performance of
'G'z work fur which this permit u issued le .309],Civ.C.)
W Inndces Name
Le wer
a Ionones Marexa
U Q I certify Nat I have tend this application and sum Nat the above information is
u. F correct.I agree to comply wit all city and county aNinances and soon laws relating to
0U III gcmtsuuclion,and beroby luNodl 1pfeunulivesafN4 city to enter alarm We
fimentionrA property fond c. action purposes.
Wo agree to save.indemnify and keep cess the City of Capenlno against
H Tq liebiliti ,) &menu,corm and operons which nary way accrue against said City
t.7 z in ca ec of Ne granting o(Ni pews. /
APPLI UNDERSTANDS A D WILL OMPLY WITH ALLJJVVON- INi Issued by: Date
SOUR E CATIONS.
!r Re-roofs
Si cert ofApplicanUComfte r D
HAZAR OUS MATERIALS D CLOSURE Type of Roof
Will We applicant or sure building occupanuimrc or handle hazardous mamriu
adclncdSac by Ne Cupenin Municipal Code. leder 9.13,and too Health and Safety
code.�enn35533(a)a �y/,,I All roofs shall be inspected prior to any roofing material being installed.
Yu ��y a
f..� If a roof is installed without first obtainingan inspection,I agree to remove
Wilt the appli tar future building occupant use equipment or devices which P g
mil hazardous air c umin nu u fined by We Bay Area Air Quality Management all new materials for inspection.
Dcoo,0
0 Yes
1 have mal the hvafMwsmawrials requimrraru under Chapter 6.95 of Nr Califon
nu IN&SafetYCodc.Savons 505.35533 3553a.lundersmrMNmifdc Wilding
J uwndY batt s tenant. t it u my prnsiinh m rwtily tite acupart f Nc
ro vim ant:which muslW mm p'onuissu sora nificate of c ancy - Signature of Applicant Date
0
Cf net oreuthonaedasrnt D te All roof coverings to be Class"B"or better