04020162 CITY OF CUPERTINO s ' �KZYY T7 7' 7 m '
BUILDING DIVISION PERMIT �Cr0NT' ', U7"&b t trr�a Ma�rrorra -',
ti H,
BUILDING ADDRESS: WAN SLI CHEN PERMIT N%4020162
OWNER'S NAME: PERMIT ISSUE DATE
iihis WAN LI CHEN
WN E:
SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=
L O p LICENSED CONTRACTOR'S DECLARATION
I Wrchy,affirm mal I am limased under Provisions of Chapter 9(commencing Job Description
i
0t5mtion7(r)of Dlvision3of tc Bus nus dProfcasiuna Cod,,andm liccnco is . s .
=� 11�ffwt, y�JL.fIO,, ,,_ _�„�,,b.lrL,-
i�z_ Lcan p f� KITCHEN RELOCATION/INT �� vCrs DEC ONY used u p Ic intends D�� �oo
9,
Is 0. Licensed Porfeasiaral
OWNER-BUILDER DECLARATION
Y 1 hereby affirm mat I am exempt form to Conlmmors License Law for the
0 0 following moon.(Section 7(1313,Business and Porfessioas Ccde:Any city or county
which rogkree a Permit In construct,alter,improve,demolish,or repair any structure
Fly poor to its issuance.also requiresthe applicant for such permit to rile a signed statement
FF < tatheislieenwdpumsuantlomcpmviarouofthe Contmclsrs Lkenm Lew(Cheprer9 Sq.Ft. Floor Area a On
k (commencing with Section 7M)of Division 3 or the Businessand Professions Code)or
Oat he is exempt temfrom and the basis for the alleged exemption.My violation of _
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3690MOfter00 Occupancy
not mem than five hundred dollars(1500). - P y Type
❑1,as owner of the pmpony,or my employees wit miss as their sole compensation,
will do to work,and to structure is not intended in offered for sale(Sec.70/4.Business
and Professions Code:The Contaumr's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himsel f or through his
own employees,provided that 911th improwmems M nminnnded mortared forsale.if,
however.to building or improvement is cold within oar yearof mmplotion,to owner-
builder will have me burden of proving that he did not Wild or Improve for purpose of
sal..)
❑1,u owner of to property,am exclusively contmeting with licensed contractors in
convect the pmject(Sec.7W4,Business and Profusions Code:)The Convulses Li.
cense Law docs not apply to an owner of property who Wilds or improves temun,and
who contracts for such projects wit a conhxmsr(s)licensed pursuant to to Contractors
License Law. -
❑IamuemptunderSec. ,B&P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
R1 hereby 40hm under penalty of perjury one of to following declarations:
emand will maimkr aC.mfiun of Consent in self-imus,far Workers Corepen.
anion,as provided for by Section 3700 of On Labor Code,for to performance of the
work for which this permit is issued.
❑I haw and will maintain Worker's Compensation Whiner",u required by Section
37W of me labor Code.for to performance of to work for which this Permit is issued.
My Workers Compensation Insurance canter and Policy number am:
Carrier. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not Mcompleted If the permit is foram,hundred dollars($100)
or less.)
1 certify Out in me mmanec of the work for which this permit is iuved.I shall not
1 1 nymwmrmumlmcomesubjwttothe Warkcrs'Compemdon
Laws sf Celi ami .Doe"'
Appl ant
NOTI ct LI ANTI,eommaking orisvisiosof of Exempt ion,you should
Wcsm jectmp n the Worker's Compensation or this provisions of ti e Labor r Coke,you mull
Q,Z (oMw comply with such provisions or this permit shall be deemed revoked.
'yO CONSTRUCTION LENDING AGENCY
'ra I Wmby affirm tat tem is a convection lending ageney for to performance of _
C4> the work to,which this permit is issued(Sec.3097.Civ.C.)
WLender's Name
Q z Lender's Add.
U Q I certify tat I have mud this application and soon that the above information u
IL'- correct,I agree to comply with all city and county ordinances and sun laws relating to
Q building construction,and hereby aulhsrim rcpmaenmtiws of this city to enter upon the
W aho,,mentioned property for IupeNon purposes
gyr esti agree m saw,indemnifyexpn tad temp harmless the City mC gamins against _ ,y
y liabiliu(We)agre in costs nand
may in any wayity of against mid City
C.)Z in consequence of the granting of this permit.
APPL ANT UNDERSTANDS AND WILL COMPLY WITH L ON-POINT Issued by:9 Date
So cER4 n S. _ B
C� Re-roofs
$i ature of ApplicouVormsctor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant or future building Occup nistom or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and On Health and Safety
code. 0No z5s3z(.n ISTNu All roofs shall be inspected prior to any roofing material being installed.
❑Yoe
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hamodous air content oaner it food by me Bay Area Air Quality Management all new materials for inspection.
District?
p Yca No
Ihavereadte Wraknos a nrialsrequimmenuundcr Chapnr6.95ofte Califon
nia Heaim&SarelyCsac,Secumu 25505.25533 ud25534.1 undcrsmnd tatiN¢building
dura not curently h w a Inane,to itis my responohility,n redly to amupanl or to
nqulrements rah WL jlpdOrmi mnracenifimno u Signature of Applicant Date
0
erRrauthoarzad egcm D Ic
All roof coveringsto be Class "B"or better