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CITY OF CUPERTINO
N �
BUILDING DIVISION PERMIT
.
BUILDING ADDRESS:
EPPIE CF LAM
PERMTTN00 6 06 O254
22446 RANCHO VENTURA
ERs NAME:
PERMIT ISSUE DATE
EPPIE CF LAM
08/02/2006
SNE:
SANITARY NO. CONTROL NO.
ARCHITEC 'ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
' Job Description
I Wrote, affirm that 1 am lisaved under provuiov of ooer 9 (oommmultil
rad Pronssiu cnde.anamy Bee is
with a=Di ainn3ofine Basin u
in un rotes
NEW ADDITION — MASTER BEDROOM AND BATHROOM 3621
License Class L'm. N
Dow Contractor
ARCHITECTS DECLARATION
I vederstand my plans shalt W used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby entreat that I am exempt fmm the Contractors License law for he
following ¢tion. (Section 7031.5, Business and Pmfcasiov Calc: Any city or county
which rcyuims a permit to construct, alter, improve, demolish. or mpair any sanctum
$77601
! prior to its issuancealso requires the applieaot for such permit to file a signed surment
tat is licensed to of de Conraral's ldceve Law (Chapter 9
Sq. FL Floor Area Valuation
lte pursuant the pmvisioru
(commeving with Section 7000) of Division 3 of Ne Best.. and Professions Code) or
that he u exempt tlamfrom and the basis for the alleged exampsioo. Any violation of
2Occupancy Type
Section 7031.5 by my applicant for a Permit subjects the applicant m a Civil penalty of
not more than Ove hundred dollars (1508).
_
I, M mncr of oe pmpeny, of my employcu with wages u eeir mte compcnsadon,
wiB da the work and theswmurt u nror intended oroRered forsale (Sec. ]D14, Burircessly
a nGns
and Pmfesslov Code: The CanuacwYs License Law does Out apply to an owner of
property who buildsorimprovv thes ereon, and whodomcltwarkhimte3for trough his
Own employees, provided Nat such improvements tie astounded oroRe ad for sale If.
however. the building or improvement u sold within ane yes of eompletion, the owner.
builder will have the burden of proving that he did not Wild or improve for "ra se of
ink).
1. as owner of ted propcny, em exclusively contracting with licensed mn0acu rs b
vt, (Sec. 7014. and Py Code:) The asounitheme, U-
of who Ire ea
a of properly who W d P or improv dtemen, and.
La des not owner
law cora not apply to an with
who
who convects for such ProKcts with a canwcmrp) Iiccnve0 pursuant to the ConuactOrs
License Law.
0 1 aI am exempt under Sec . B At P C for rescan
Dots
0.'S COMPTNSATION DECLARATION
I hereby aVtw under penally of perjury one of the following decletiion ,
rj 1 hi and will maintain a Certificate atonement in self -insure for Woremi Compcn,
sation, as provided for by Section 3708 of the Labor Code. for the performance of the
web for which Nu permit is issued.
❑ 1 have and will maintain Warlem's Compensation Insurance, as roquirod by Section
3700 of the Labor Code. fm Ne peRarmance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
musaccons treed not ho completed lithe .it is fm ane hundred daft. (SI00)
or less)
1 cenify east in the performance of the work for which this Permit Is issued, I shall not
employ any person in any mamter an asps(coma bYGt totpd�Varkm'Compensaeon
Laws of Califareia. Date — /y�// r9
Applicant 3
NOTICE TO APPUCA rakng this 126t empban, you should
b¢ome suM1ject m Ne r Ya Compensation provisions of de Ldn r Code you must
' forthwith comply with such provisions or this Permit shell ho deemed Ovokce.
CONSTRUCTION LENDING
1 W, that them is construction ngagerAGENCY
leneinp agency for the perfurmasnOa of
' whelBw
s d(Sao
for which Otis .it is issued (Sao. l09], Civ. C)
Le dworkors
Lenders Naroc
'
L<ndcrs Address
1 I sioily that 1 have read his application and state that the shove infprmadon is
'
' cows 1 agree in comply with all city and county Ordinances and suite laws relating to
building conslmctiOn. and hereby autherivc representatives of this city to enter upnn the
IWn 'Iaemmned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilitioujudgments,costs and expenses which may in anyway acerae against said City
in consequence Of the granting of h6 permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
SOURCE
Date
REG L TI NS. _�O
Ute` o
Re -roofs
Type of Roof
Signuurto caD te
HAZARDOUS
HAZARDOUS MATERIALS DISCLOSURE
Will Circ applicant or forum bpal Co occupant store or handle an material
az de0vd the Cupertino Municipal Code, Chapter 9.13. and he Health and Safety
Health
'Ie,. Section 25533(x)?
io
❑Ya �No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
P g
emit hurardous air contaminants u defined by he Bay Arca Air Quality Management
all new materials for inspection.
District? /
❑Yes A.
I have, mad dm hmandous maawrials requirements under Chapter 6.95 ofthe Cxlifa,,
nu Health A, SafetyCede, Sections 25505.25533 and 25534.1 understand ha if the Wilding
dm not toncody have a ¢mane that it u my w y a notify the a upon, of he
reqirem
uents m whichpriarroissa . enifica¢of s
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authoundVint p,�