05060114 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ��kNeTRA,CTORNFURMATO ?'
BUILDING ADDRESS: ADMIRAL CONSTRUCTION ""'"'ND'05060114
7678 PEACH BLOSSOM
OWNER'S NAME: PERMIT ISSUE DATE
ANDY SHIA AND MARY NG 656 BEGONIA WAY 2005
ONE: SANITARY NO. CONTROL NO.
(408) 309-5981
ARCHOECU GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
poi; LICENSED CONTRACTOR'S DECLARATION Job Description
I I hereby affirm that 1 am licensed um cr provisions of Chapter 9(commencing
with Section 70(11)of Division 3 of No Business and Professions Code,end my Ikon¢is
A I.full roroeandeffec ADD 5531 (LIVING RM) & REMODEL
in' Uemn 1=a - Contractus $ 3 KITCHEN/MS BATH/CHG ROOF/FURNACE
tit: ARCHITECTS DECLARATION
u-IS 1 understand my plans Nall he used as public records
�6
Licenced Pmfcuional
y OWNER-BUILDER m Ce Conv ON
I I hereby waso .(Sero Net 1 1. exempt from the Cantns Co License C Law for the
p o following moon.(Saito 7 construct.
Business and Pofcssinns Code:Any dry art crumy
$(L which requires a permit m consvuet,sites,Improve,demolish,t lir repair any structure prior m its issuance,also requires the applicant for such permits Ole uigned statement
. b< that ha is licensed pumumt to the provisions of the Contractor,Licence Law(Chapter 9 Sq.Ft.Floor Area Val$ Or0000
gg� (commencing with section 7")or Division J of the Business and Professions Code)w
la exempt thercho o
5 3 that he and th basis for the alleged esemption.Any violation of
Section 7031.5 by any Applicant for.Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not room then 0.e hundred damn(ML 36611115 . 00
❑I,u owner of the pmpmty,m my wploycu wW wages u their sole compensation,
willdo thewmkandth.ahacmmisnoUntenftdwnffered fwum(sec.tas,Buimeas Raired-Iactions
and Profauians Code:The Comrmtar's Lim.Law docs set apply m e n an.1 of q /`^�
property who build.or improvestinown,andwhodoesauch work himselforthrough his
own employees,provided that such Improvements are not intended aroffenA for sale.If.
however,the building or improvement la mid within one year ofmmpledon,the owner. ' J� IG✓—,)
builder will have the burden of proving that he did not Mid or improve for purpose of
talc,),
❑L u owner of the property,,Business uand conbmting with Ilcewm conr.man -
conse Lathe project(Seepply]aa, 000fand Pr.wito na Cmc:)Them thamon, red
cence law coca not apply m U with
a of properts)iwa sed p at impnw thereon,sed,
who contracts for such prok<la with a contractor(s)licensed pvnwm in the Conumsrr's
Licence Law.
❑1 oro exempt under sec. .B&P C for this recon
Owner D.¢-
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury sae of We following declamiona:
❑1 have and will maintain a Certificate of Concent to self-inaum fm WorkeesCompen-
ution,As provided for by section 3700 of the labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As acquired by Section
3700 of the labor Cmc,for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Nla Mellon need not be complaints if tie(erwit is wrone hundred dollarx(gld)
or icer)
1 cew(y that in th rformance of the work for which this permit 6 issued.I shall not
m I en ro i an met�cr/ny sob cpme sub'rµt hetVorkeri Com wa0on
Levis of Celt mi e y IAJ-o I w')uU
Applicant lig g
NOTICE TO AP g this Certificate of Exemption,you should
become mbJcel m tion provision of the labor Cone.you muss
.JO forthwith comply wit such provisions or this Permit shell be deems revoked.
pi� CONSTRUCTION LENDING AGENCY
F•t Ihereby affirm that them is a construction lending agency for the performance of
D:�. the work for which this permit is issued(Sec.3(y97,Co.C.)
dQ (anda Name
D z Leader,AdaMv
U 0 1 certify that 1 have read this application and mute that the above Information la
is, correct.l agree to comply with all city and county ordinances and awe laws relating to
0 building construction,and hereby authorize mprowmativa of this city m enter upon the
W show-mendonm property for Inspection purposes.
Py (We)agree to save.indemnify and keep harmless the City of Cupertino against
IV] Ila Ilities,Jmgmens.c..m and expenses which may in my my am=against said City
is n,egwnce fthe granting of this pcmait.
A [CAW DERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO
0 —I - Re-roofs
si • Dem Of ROOF
HAZARDOUS MATERIALS DISCLOSURE Type
WIII the Applicant Cupertino
w(atom building Occupant atom or hands h callow material
As dcRncO by the Cupertino Manic' el Cone.Chapter 9.12,seri the Health and Safely '
Code.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yue No
Will the applicant at future building wcupam um equipment w devima which If a roof is installed without first obtaining an inspection,I agree to remove
It hayardow Aircomaminanta Oncd by the Bay Arta Air Quality Managcmenl all new materials for inspection,
DisuieR
❑Yes Nu -
Ih mad thehwA teas materlelsrryuiremcnu under Ch"terfi.95orthe Califon
nlelfcolth metyCmc, dons25N13.13333 uW133J4.iundontand thul(the building
due.not c oily haw a te anis that It is my responsibility m notify due occupant of the
our.MO. h l r us=of.Camille.te arOcempaney. Signature of Applicant Date
Owner ora thorned,gem J ' perm All roof coverings to be Class"B"or better