05070059 CITY OF CUPERTINO �tw,sw .#:� •r` -=:�= '.�a'-"3'd��`
BUILDING DIVISION PERMIT ICON=TAXOT-OR INFOItMATIUN �
BUILDING ADDRESS: _ PARKER PLUMBING PERMITNIb5O7OO59
19323 PHIL LANE
NER'S NAME: PERMIT ISSUE DATE
W
HENRY S KIM 24 CHELTENHAM
PHONE: SANITARY N0. CONTROL NO.
(408) 374-1832
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0
Stop LICENSED CONTRACTOR'S DECLARATION Job Descri tion
1 1 heNreby affum that 1 am licensed under Provisions of Chapter 9(commencing P
MSection 7011 of Division 3 of tie Business and Profastions Code.and my licence Is
''ate in full forteandcRan. TAP OFF W LINES -EXTERIOR TO BLDG.
ig? Da¢nce Clem C sector
RUN UTIL O OFF ELECT LINE
9ty�'f
ARCHITECT'S DECLARATION
Sr 1 understand my plan shall be used u public manor
illiO Licensed Professional �oo�
p OWNER-BUILDER DECLARATION '�Q6.
3�2 I thereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section 7031,5,Business and Professions Code:Any city or county
$ which requires a permit to construct.alter.improve,demolish,or mpair any structure 1%11 MIR
F-Zr prior m its issuance,alae mquins Oe applicant for such Permit to file s signed statement
that W is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 -r re ValuaoW 0 0
F $ (commencing with Section TODD)of Division 3 of the Business and Professions Cock)Or
that ha is exempt Nemfmen and the basis for that alleged ascription.Any violmion of
Section 7031.5 by any applicant for a person aubjeats the applicant to a civil penalty of APN Number Occupancy Type
not more Own five hundred dollars(SSW). 3 7 5 0 5 0 2 6 . 0 0
❑I,n owner of W property,ver my employees wiM wge m theircele mmpewdon,
will do the work and construct.h not Inleaded ver offered for age(Sec.70414.fh doess
and Professions Cade:The Contractor,Licence law arcs not apply to an owner of Required Inspections
property who Wilds or improve themon,end who does wch work himself or Uuuugh his
own employee,provided matsuch Improvements tie not Intended orofiered formle.if,
however.the building or improvement is mid within one year of completion,the owner.
builder will have dor burden of proing that bo did not bald or improve for purpose of
sale.).
❑1,As owner of the property am exclusively contracting with licensed cantsacmn to
construct the pmjem(Sec.7011,Business and Professions Cade:)The Contrmcers Li.
came taw does not apply to an owner of property who builds or improv Norton,and,
who contracts for such pm*m with a eonuacto*)licensed pursuant to the COmmtOel
Licence Law.
❑I un sem Wd�er sec .B dP C ver this ton
mer rt('-�'� Date— l
/ I 0
WORKER'SCOMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of to following declarmiom:
❑1 haw and will maintain a Certificate of Consent to self-insom far Workers Ccmpen-
motion,m provided ran by Section 3700 of the Labor Code.far 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 Code,for the Performance of me work for which this permit is issued.
My Workers Compensation].am.Grier and Policy number am:
Carder. Polley No.: ,
CERTIFICATE OF EXEMPf1ON FROM WORKERS'
COMPENSATION INSURANCE
mAlA section need not hecomplemd Who permit is foram hundred dollars(SI W)
lir less)
1 certify that in me performance of the work for which this Permit is issued.I shill not
emplaymypermninmyms �fG mbjcetmme Workers'Compensation
Lam of Cdifo/m/y/P�r•
Applicant
NOTICE TOA .IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you most
.,O forthwith comply with such provision or this permit shall W deemed masked.
z y CONSTRUCTION LENDING AGENCY
[+ I hominy affirm that inert lsa construction lending agency for the Performance of
ai me work for which this permit Is issued(Sec.3097,Civ.C.)
LaQ Lender's Name
:1 z Lender's Address
C.)Q 1 certify that T have mad this application and state Rte use mhos information is
lL ^ cores 1 agree to comply with All city and county ordinances and mw laws refining to
Q SV' building contraction,mud hereby mhodm representatives of this city to enter arm,the
[77 abovcmentianed Property far inspection purposes.
py (Wc)agree to cove,indemnify and keep harsnlesa the City of Cupertino against
fA liabilities,judgments,costs and expenses which may In my way acme against said City
C.37 in CMACIuence of me griating of this permit.
�i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURC%REGGULATIOONNS.
f�ol� Re-roofs
Signature of ApplicanUCoData
HAZARDOARDO US MATERIAL$DISCLOSURE Type of Roof
Will tie applicant or forum building ompatuam ver huddle hmudoas mamdai
defirctl by the Cupertino MuniNpal Code.Chapter 9.11.And Ude Heath and Safety
Section x553:(.)7 / All roofs shall be inspected prior to any roofing material being installed.
[D Yes Lyro
Will tie applicant or future banding Occupant am equipment or devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
emit hasardous air comaminams m dc0ned by the Bay Ams Air Oudhy Management all new materials for inspection.
District?
❑yes 84u .
1 have road the hntrdne materials mquimments under Chapter 6.95 of the Califor-
nia Health&S'afelYCede,Sections 25505,35533 and x5334.1 understood that if the Wilding
does cot curmady ham a tonanl the,it u my responsibility w notify the aceuPmt of the
ac en hlehmuuWmet ortoivuancea(YCenifiesaf a Signature of Applicant Date
q pd
�' r r '0 All roof coverings to be Class"B"or better
Owner ver authomad agent IDam