05040007 CITY OF CUPERTINO
BUILDING DIVISION PERMIT a�,CONTRACTORIIVFORMATIO.N lea _
h k,
BUILDING ADDRESS: HWANG YOUN 0 AND KUK ^Y V P�"'11%5040007
1624 PRIMROSE WX
ER'S NAME: PERMIT CSUE DATE
HWANG YOUN 0 AND KUK Y
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMMNFO
BLDG ELECT PLUMB MECH
(=
Zoe, LICENSED CONTRACTOR'S DECLARATION
�u I Wroby afrrm who I am licensed under Provision of Chapter 9(commencing Job Descripti m
with Seorce andlo)of Division Sof NC Business eM Professions Code.and my license is � tj
Li,,n.full «anderren. ADD 265 ' (DEN RM) CONVERT 6 II IISJea
j�z License class Lie.g
Z� Data contractor (CONVERT GARAGE TO BATHRM)
ARCHITECTS DECLARATION //11
U 1 uncersund my plans shall W sued as public records
2006/ It
36 u. Licensed Professional 4
50� OWNER-BUILDER DECLARATION
.�0 I W ors.Trent on 11. exempt from w Conuaesors e:Any c taw for w
i o o following sawn.($codon IIIJLS,Business and Rofcssiuu Calc:Any city or county CBIS Ik97 L✓�` \VTHS
S which requires a permit m construct,alter.improve,demolish,or repair any structure
FZ<
poor it,its issuance,alsowrite.wapplicat rmuch Permit to file.signedsutemem
£ NatWislicensed pursuvmmthe prov,smsfdwConuutee.U.nxLaw(Chapter 9 Sq.Ft. Floor Area Valq�q(Mo00
e(�m (cammcaing with Section 7000)of Division 3 of the Business and Professions Cow)or
y that he u exempt wrtfrom and w bus for w alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant in a civil Penalty of APN Number Occupancy
not mote daneew lira hundred dollau(M). p Y Type
❑I,uowmrofNepmpmy.amyemployeewiNwageuwbwlcco th=e on, 36615008 . 00
will do dteweak.and w.uscmrt ism,intended moffertA forsa a(Sec.704,Business
and Professions,code:The Contractors Llccrse Law does not apply b an owner of Required Inspections
property who builds or improve thereon,and who dues such work himself or through his
own employee,provided Nat such improvements are not ins muttered for,saw.If.
however,the building or improvement is sold within one year of oompletwn,w owner.
builder will have w burden of proving that he did not Wild or improve for purpose of
sainI
El 1,as owner or the property,am exclusively contracting with licensed comoclnra to
construct the pmject(Sec.7064,Business and Professions Code:)The Comment's Li.
or=taw docs no.apply man owner of proper who W ills or improves wrcer,and.
who contracts for such projects with a contractor(s)licensed pursuant to the,Contracmrs
License Law.
❑I am exempt under Sec. ,B&P C for this rtuon
cr 77 Dale ,
WORKER'S COMPENSA7 N DECLARATION
I booby affirm under pwlry of perjury one of the rollawing decluatiou:
let:have and will maintain a Certificate of Consent to xlRinsure for Worlses Comped
n,az provided for by Section 37M of the laWr Code,for the performance of the
for which Nis permit B issued.
have and will maintain Worker's Compensation Insurance,a required by Section
of Ne labor Code,for the performance of the work for which this punnit is issued.
Worker's Compensation Inwmnce coria and Policy number art:
Policy Na.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sectisn need not Necompleted ifft permit is Furore hundreddollars(SIM)
or less.)
1 ter iry Nm in the performance of the work for which this Permit is issued.1 shell not
employ any pawn in any mwncr so as m become .Ne Work..Compensation
Laws of California,Doe — —
Applicant -I...n o-
NOTICE TO APPLICANT,IL after making this IFcnificale of Exemption,you shu ild
Weems subject an the Worker's Compensslien provisions of w labor Code,you most
Qz forthwith amPly with such previsions or this Permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[—� I hereby affirm that them is.construction krulft.percy for the Psufroommoeof
tYi
we work for which this permit is issued(Sec.3097.Civ.C.)
OW. 0 lender's Name
Q. z Uneces Address
()Q I certify Nat 1 hawply read this application and sate Net the about information is
wilding 1 Agree m comply with all city asci county ordinancesresof and sou laws r upon
m
Q U Wilding cononewl construction. Ins euthoda rtprexnutises of Nu city reenter u��nw
aWsc(we)are to saw.
and keep
Er+ y (We)ague m uses indemnify rod kith humwss the way Action,
io Cupenino id City
Z in
ncosegjudgmentse gowning of dhisesmit. may in any rosy agaae.gsestsad City
U z in consequence of Nc gowning of this Permit. �
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of ApPhcaVCoARDOURe-roofs
— -
HAZARDOUS S MATERIALS DISCLOSURE Date Type of Roof
Will y to Cucanl a future Municipal
Co occupant.Chpter me 9.12,handle Health ue material
az defined io Ne Cupertino Municipal CWe.Chapter 9.12.and the Health and Safety
Jc,
Section 8532(x)?
pYes Otho All roofs shalt be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection,I agree to remove
Will Ne 11 color or furore building occupant nsc equipment it devices which p g
emit ha'ralloa aireonuminmuudefined Wyw Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes (]No
1 have mad the hvardnuamatenals mquirements under Chapler6.95 ofw Califor-
nia Hcalth&SarctyCode.Scetiom25505.25573 and 8534.1underswal Nm ifw Wilding
Jianot currcndy have a tenvnh No it u my respoaihiliry m nctify w.cup ons of Nc
mquircmcros whim no. ppoor no a or acadBcaleoraayancy Signature of Applicant Date
i Su- 9-45
Come,or.uthori ed agent Date All roof coverings to be Class "B"or better
' L