08010097CITY OF CUPERTINO'dr9pt9��a
PERMIT
IYTRACOR`�IN'1+nURMATI s
BUILDING DIVISION
��',
BUILDING ADDRESS:
PERMIT NO.
10121 PASADENA AVE LOT 1
TBD - TO BE DETERMINED
08010097
OWNER'S NAME:
PERMIT ISSUE DAIS
IOJYAN-PING'LILY CHANG
03/11/2008
NE:
SANITARY NO. CONTROL NO.
ARCHTIECf7ENGINEER:
-
BUILDING PERMIT INFO
'
'BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I Wroby office than I me IkeNSW under provisions of chapter 9 (commencing
Milt Section 7") of Division 3 of the Business and Profcseom Code,md my license is
DEMO ERSTNG SFDWL-DTCH GARG
In full farce and cfTwL
License Class Lk, is
Dau Contractor
ARCHITECTS DECLARATION
1 undersuml my Plana mail be used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby .11. that 1 are exempt from the Convenor's License Law for Ue
fallowing motor. (Section 7031.3. Bedroom and Poetess.. Cade: My city m county
which requites a permitto cnnmroct sitar. improve, demolish, or repair my eroaure
prior be its whimce, Mo. mgolrca oil applicant for soh permit o his atogried stskment
that he is licensed to the of the Conmcter'e Lw Law(Clupte, 9
Sq. Ft. Floor Area-
Valuation
p osunt previsions ran
(commenting with Section 7000) of Division 3 of the Business and Professions24
Code) or
00
that he Is exempt watchman and the basis fm the alleged exemption. Any violation of
Y Number
Occupancy Type
Section 7031.5 by any applicant two permit sebjecu the applicant to a civil penalty of�,p
set msec duo five headred dollar, (SSW).
3 5 717 0 4 5 : 0
❑ 1,aowner attlie property.amY ernPleyca with wgesu Near sok cmnPawUon,
Required Inspections
Lo sen
and PPrremaues Cube Th co wethers Liume, an, apply in son w.o'af
property who builmarimpmvea thereon, andwho dasamhworkhimsel(er Wough his
awn employers, provided that such Improvements art not inunded erofwmed forsele If,
however, the building m Improvement Is sold within one year of mmpledon. the owner.
Wilder will have the tandem of proving that he did not build or Improve for purpose of
alo.l.
. 1, a owner e( tie property, em a clud"ly contracting with Ummed mnrnctou w
construct the pmjea IS. 7094. Become, and Prefeseaes Cama lose Comrntor'i U.
ansa low does not apply to an owns of property who toolm or Improves t evert. and,
wino contracts for such pajecu with • connector(s) Emitted purmum to the Contrsaor's
Lktve Law.
❑ Ilan exempt coda See .B d PC for Nu ream
Oeu 31 It D-
/WORK PN
'S OMPSATLON DECLARATION
r
lite y/aM. under pvWty of perjury one at the fallowing declarationsancho
'
❑ 1 have ono will • CeNMts of Consent locum Worker's
provided for by Section 3700 a( the Labor Code, far the performance of the
for by r Cul the
markr t
wart far which Nis permit is touch.
❑ 1 have end will mentsw Water's Compensation I.., as required by Senior
37W of the Isba Com, fm the poformarue of the work for which Nis permit is leaned.
My Worker's Compensation Wunnx conies arta Policy number ere:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thk section nand set be cam kited if the Permit is feroue hundred dollen(SIW)
or loss)
I unify, out in the performance of tier work for which this permit Is Wrote. l Ault me
'
cnployanypermemanym [[myyubaome subject m UU Workers'Compuuation
Ise ofCal Dau\\\I nlS
NOTICE TO APPLICANT: IL afar making the ocitialFine, of Exemption, you AuuW
become subject 0 the Worker Compensation provisions of the Lobar Code, yon intra
forthwith comply with smh movidms or Nu Permit abet W doomed meted.
CONSTRUCTION LENDING AGENCY
1 hereby afron that Nero N a command. lending agency for the performance of
the work rat which this permit la whose (Sec 3(197, Co. Ca
Le me, Name
,
Irnlor's Acorea
1 certify the I have read this application W sum the the above hownwatim is
"
curreo. I agrce in comply with all city and comty otdinarKa and suer laws Ruing he
Wilding mesvueUan, arW hereby smhmtu representatives of this city to cotes open the
above-mcedoned properly for inspection purposes.
(Wo) agree he ave, indemnify and keep harmless the City of Coperino against
Ilablltdes,judgments, emu and expenses which may in my way a.. a1iles9aid City
In consequence of the granting of this permit.
APPI. NT GNDERSTANOS ANO WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC EGG ON ,
Re -roofs —
Type of Roof
Slgnm ofA i onusetor Dau
HAZARDOUS MATERIALS DISCLOSURE
Will we appilcmt or f ttom building onupmtmore or handle haardom maurfe
defimd by the CupeNm Mmkiryl Cade. Chaput 9.13, and the Health and Safety
ask. Section 25531(x)?
Yes on
All roofs shall be inspected prior to any roofing material being installed.
fi❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building oavpant use equipment at devices which
t hrrordnw ate cmnminmu u refined by we Bay Ams Air Quelty Management
all new materials for inspection.
DL'ICfl
❑Yrs PTNo
I have most the heaNauameusialamquimmenu underCMpw6,95 of de CaRfm-
nlaHutahSafeyCode,SrNw25505,25533 and 25539.1 urdmsuM thnifoe building
it= set curmo dy�heves (cern that It is my nespontioility, in reify the occupant of du
mquirtmmn mambemet inLa..f. kauofettepecy.
Signature of Applicant Date
�e °
All roof coverings to be Class 'Ra' or better
Owner Dow
or scarived.gem