01070148 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: IDI PERMIT NO.
2.2 3,i6 4..,RAMONA,__CT-----'--------------...__ _.... .--
} ' "OWNER'S NAME: - , „ ., APPLICATION SUB DATE
HENRY WONG 07/30/2001
PHONE: SANITARY NO. CONTROL NO.
C se0 O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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c z v=Ni_ LICENSED CONTRACTOR'S DECLARATION Job Description
O z_,� 1 hereby affirm that 1 am of th B under provisions of Chapter 9(commencing
r_Fa, wtnfuceoneandefect. mn3anheBa.meS.andrrerew.lon.caeaaaemyhcenS= ADDITION 135 SQ. FT.
s`x m ce ren mate dna erred.
Kiam
License Class Lic.a
0 so Da -
w u3.a y ARCHITECT'SS DECLARATION RATION '
�—O< 1 unJcnwnd my plans shall be mond as public records
Licensed Professional 1 Nq L ea
OWNER-BUILDER DECLARATION
w o m 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
E 3< fallowing tea.nn.(Section 7031.5.Ra.inese and Ponfes.i°ns Code:Any city or county OUT 'rr.n
Y x p which requires a permit m construct,alter,improve,demolish,or repair any snunurc ]s W
i n' pct t t- Sas Iso qu h pplca f apeman FI g,J.mtmmm. - - - - - ._-- -
lbathqislitvnwcip Ito lM.,l xl aftlic Contractors Lunnor Lin,'(CI-Mery
i . .. a[IOnu0G
lea y IhSeu 7UOv fU' . 3.1th Bine dY f. sCWe) 3J
Bull ow.
or that he is exempt themhom'and the basis for thealleged exempi oilAny violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
afaatmoremanfive hundred dollars(S5u0)' 101APN 16ftATION , . . PancyType
: Cl as owncronne prP tY Y employees withwagesas theirsoll compensation, -......._,
will do Ibe wmk,and thet t s t t J d ff d f s (S c.7044, ..
Bustles.and!Pmfeu CodTh Cnt L La a t apply to an 103'==- UFER Required Inspections"
owner of pmpeny who builds or mmprves thermal,and who does such work himself ,
or through his own employee.,provided that such improvements am not intended or .. . 104 _.- REBAR
,offered for Sale.IL however,the building or improvement n sold within one year-of ••
completion,the uwnerbuilder will have the burden ofproving that he did not build or 105 - ANCHOR BOLTS t
improve for purpose,or.me.l. 106 - SEWER & WATER
_. ._ .
r project Tec.7(A4.exclusively Profit contracting withlicen.uut Contractor's
nctotam 202 — UNDERFLOOR PLUMBING '
iecuuct the present(Sec.7111a.Orman..and city who b Coded The improves
thereon,
Licenu raw tract not apply loan owner°fpr°pnny who)aims seimpmva thereon, 2 03 — UNDERFLOOR MECHANICAL'
and who ranwens rat wenn prmian .wath a nmmmmm�S)licensed pa moat to the. -2 04 - UNDERFLOOR`FRAME
- Cmmnnor'.License Law.
elimexentpt oder Sec. '' .B&ISCfor this reason 205 — UNDERFLOOR •INSULATION
Owen W COMPENSATION DECLARATION
301 — ROUGH PLUMBING
302 — TUB & OR SHOWER
I hereby affirm ander penalty of perjury one of the following declarations:
303 — ROUGH MECHANICAL
❑ I have and will maintain 5 Certificate of Content m self-insure far worker's 3 04 — ROUGH ELECTRICAL
,. Corpcnmtion: as provided far by Section 37W of the labor Coda for the
.. performance cr tlm work for which this permit is issued., 305 - FRAME
❑I have and will maintain Worker's C°mpcnsaimn Intmance.as ur,mmd by Section 3 06 — HOLDOWNS
3700 of the Labor Cale,for the performance of ren work for which this permit i. 3 0 7 — INSULATION
issed.MyWorkersC R t lmumma canter and Policy number am.
Carrier Policy No ,,n s s , m3 08 ., ,SHEETROCK 1 .. .... . -
ChRTIIICATIONOF EXEMPTION FROM WORKERS' _ _ 309' '_=` EXTERIOR'_LATH
''
_. _. COMPENSATION INSURANCE'. .. _.,I .. - ._.. ._. . . -..__.--.—. .... .. -..._. __._...
rnas Section nEal'not x innnNeteJ fine permit is far one hundred donor. - 3101 INTERIOR LATHS
celWlar m,sw.l _ 311 — SCRATCH".COAT " ,• ..�.•;•�.
- .I certify that n the Iedonacrom of me work far which this permit is issued,I 313- ROOF 'NAIL',, .
'ahall not employ any person in any manner an as to become subject to thc Workers 501 — FINAL ELECTRICAL 'ENERGY
C°mpcncatlmrn Laws of Cabfornu:Dam
Applicant " 502 FINAL PLUMBING ENERGY
NOTICE TO APPLICANT:IL after making this Cenificare of Exemption,you should t 1
Z becommm
ebjecttheWor4ersCmaconimnprovisionsminelabor&x,youin.,, 503 — FINAL MECHANICAL ENERGY
O O f°nhwahcomply with such provisions orthis Permit maubedeemedrevoked. 504 — FINAL BUILDING ENERGY- ,
CONS'TRUCT'ION LENDING AGENCY SOS — FINAL ELECTRICAL .
1 1 hereby affirm that there is a construction lending agency for the perfem Ove
of the work far which his palm,is issued(Site 3097.Civ.C.) _-_-,_, - .506 - GAS TEST _ . .
Q Lender's Name -- " - --
Lender'sAdd,c,, 507 - FINAL PLUMBING ,
U 0 I certify that l have mad this application and sum that the above information is 508 — FINAL MECHANICAL
(z E: correct.I agm,m comply with all city and county,ordimnce,and state laws relining 509 — FINAL GRADE
O t1 to building construction.and hereby uutborizc representatives ofthis eqn.enter upon
>, va mean°vermemulodpmpcoyra,in.pcctimnpurposes 510' — FINAL PLANNING
F y (N'e)agree m save.indenml ly and keep hatmles<the City°f Cupenim,ri,oml
'✓] liabilities,judgments,costs and expenses which may in any way accrue against said 514 —
FINAL PUBLIC WORKS ,
f) Z City in consequence of the granting of this fnrmiL.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued) Date
SOURCE REGULATIONS. Y'
Signature.1ofAPPlica AZARDOU .Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE a
Will the applicant or future building Ocampent store rn.handle hamrdous material Type of Roof .. .
as dcfned by the Cupertino Municipal Cale,Chapter 9.12,and the Hen III,and Snfcty'
Code.Section 255321p1'. m s m '. {� .j 1 {' s`. . T' -
❑Ye. • ❑N°' - -, _._ All.roofs shall.be.inspected.prior to any.roofing material being.installed. .. - .
Win.theappli ,or future Inulding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I,agree to remove
emit Ivzzrdaut air c°nmminand as defined by the Bay Area Air Quality Manngemen
District .. -. _all.new,materials for inspection.-.Applicant understands and will.comply.with... .
-Oye. ON. - all non-point source regulations., ..
I have read the hazardous materials requirements under Chapter 6.95 of the.
California Health&Safety Code.Sections 25505.25533 and 25534.1 mmderstand that .. ..
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
' Signaturc.of Applicant _ - _ . Date
Owner en anthonaed agent Date All roof coverings to be Class `B+' of better' .
.. .. •- T- OFFICE