05100172 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CUNr"GT0RRNFU FtITION:BUILDINGADDRESS: ADMIRAL CONSTRUCTION PERM11NO.05100172
78 PEACH RT.nqc:rim np
NER'S NAME: PERMrr ISSUE DATE
ANDY SHIA 658 BEGONIA 10/21/2005
HONE: SAN IARY NO. CONTROL NO.
(408) 309-5981
ARCHITECTfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB
MECH
O
O z LICENSED CONTRACTOR'S DECLARATION
I berc6y affirm Ws I am liceuad under p avldeu of Chapter 9(commencing Job Description
with Scion 7000)of Division 3 of de Business and Pimmadum Cade.W my license u
is full forceand effect. REVISION-KITCHEN/BATHRM CLOSET
�gz_ Lmmsc Clue Lie.N
Dam Contractor
sasp ARCHITECTS DECLARATION
1 understand my Phan.Mail he used u public re nrda
3
A tad Lk)nsed Professional
OWNER-BUILDER exempt m DECLARATION
<q 1 hemby ahem o n 1 am eusin from dr )comas ra License law for tie
00 following moron. ecolon 7031.3.Business and w,de um Code:Any city ear county
SI$r which ram issuance.
•tenon ac convect alar,Improve,demolish.t ri repair any suuctum Q
�' prior m is,issuatepursuant to the de applicant of thatch permit rile a Law(Chmmenl
'pS< that menccnudpursuam70th)ofDiviomnrmcheBucmr'sLlcenulso(Chade)ar Sq.Ft.Floor Area Valuation
y�� that he is exemng pt Sectionern and the
Division f r of m)Budnexeandmpt Proon.Any vi Cade)or
�.. Nn he ta exempt anmrrom and the bub far be alleged gumption.Any violation of
.at
7W IS live
hundred
applicant for•permit subjects the appllunl m a civil penalty of Occupancy T
not moa gan five hundred do1Hn(5X10). p y YID
❑I.uonerofthepmpmymmyemploye wlthwgnutebmlewmpenudon.
will do theworltand the suuoure is netmunded oreffersl forade(See.70th,Badness ,RC Required los eCt10Ds
and Profusion,Coda:The ComoMmes Liam Law does Inst apply m an owner of q
property who builds or improves thereon,and who doss such work himml f or through his
own empeu,provided maoshimprovemam not mortered r
however.the Wilding or Improvement r sold whom one year ofmmpation,Me owner.
�V
builder will ban the burden of proving that he did not bald or improve for purpose of
tale.).
1.u maser of the property,am excludnly Mounting with licensed contractors to
comtroct the project(Sec.7014,Business and Professions Cade:)The Cenuacmes Li.
acne law does nm apply to an owner of property.who builds or Tmprowa thereon.and,
who contmcs,for such projects with a comracmr(s)licensed pursuant In fie Canvacmes
Lkenm Law.
Cl am exempt under See. 4z 1 44 ,B&PCfarthlaroaaon
erDau �% O
hereby EiWO CER'$LO NSATION DECLARATION
1 heby aau under penalty of perjury aro of the following declan0au:
❑1 ham and will maintain aCiedfine atonement 70 self-Insure far Woftes Compen.
,a0an,as provided for by Section 3700 of the labor Code,fm me performance of the
work for which this permit is Issued.
❑I ban and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for thC poformanee or the walk for which this permit Is Want.
My Workers Compensation Insurance natter and Policy number are:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7Ttaucdnn aced notMcompleud HIM permit Is farm.hundred d011ass($IW)
or kso.)
I certify that in me performance of the work for which this permit is Issued,I shill not
employ any person in any mmncrw y m JM1p(n�e�whiaf tome Workers Compewlion
Laws Califamia.Da¢_vL_...Li+"MAI
r L f` i!Z,
NOTICE TO APPLI Aaf. r making this Cemfrcae ofof cmpa
become subject m the Work Compensation provisions or the Labor Code,you must
O forthwith comply with such provisions or this permit Mall be accused ranked.
rM CONSTRUCTION LENDING AGENCY
(-I I hereby afllim that Nem u a construction lending agency for the p)rfermanc)of
C� the work lm which this permit b issued(Sec.3097,Civ.C.)
Q Lenders Name ,
.7 z lenders Addrau
fJ 0 i certify that 1 haw read this application and sum that the above information is
ly F correct.T agree to comply with all city and county ordinances,and sum laws mining to
0U building construction,and hereby authorize represenmives of this city to carr upon the
Cil above-mendoned properly for Inspection purposes.
(We)agree m taw,indemnify and keep hatmles,the City of Cupertino agdmt
L.i y Ilabilidea.)Wgmenu.colds,and expenses which may in say way acme larli Wit City
L)7 in eonnquam of the granting of this permit.
tom— APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
slenatar)arAppueandeon/ A � oar �
Re-roofs SaJD :
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the WPIICMt or rut=Wilding cautious more or handle huardous mamdsi
as defined by the Cupertino Municipal Code.Chapter 9.11.and the Health wd Safety
Seton 25532(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ym �No
Will r applicant or future building oct:upam use equlpmam or deutons which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaamnus air coommicnu as dcfinca by the Bay Area Air Quality Management all new materials for inspection.
Diwict7
❑Yrs No
I haw reW the haundsms mami.Is requirements under Chapter 6.95ofthe Califon.
nit Hralth&SnetyCode,Secdons 25505,25533 and 25534.1 undersuM that ifthc building
does not currently hart a arrant,Wt it Is my rupoui0il ity m Madly de acaupeal of the
mquimmanu which mum oft- is, ncafaccrtiMantdo7c ocyr Signature of Applicant Date
owaerar.amadnda ag Dae All roof coverings to be Class"B"or better