03110030 CITY OF CUPERTINO ° ��°�`
BUILDING DIVISION PERMIT C ,
BUIL DING ADDRESS: NICE & RIGHT CONSTRUCTION ERMIT'03110030
2
ER'S NAME: PERMIT ISSUE DATE.
' BEN LEE & DE
NE: SANITARY NO. CONTROL NO.
(415) 239-2696
ARCHITECr/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
woo LICENSED CONTRACTOR'S DECLARATION --
'r1 b I hereby affirm that I am licensed under provision,of ChaPmt 9(mo mcncmg- --- _ Job Description
A]j ithSection 70III)nfDivision Softhe Business and ProfeaalonsCode,and mylicense I.
mronmmaanderceet. - DEM
5'N= Licenw Clma Lin.a
Dam Contractor_
As shuth use DECLARATION _,_LD
1 undcnanJ my Plein shell h tired m public records
D U �.�/ \
3� Licensed Professional
0 OWNER.BUIWER DECLARATION I hereby affirm than 1 am1. exempt form the Contractors License Law for the
5:0 O following mama.(Section 7 o 1.A Buatoess and Pus.demolish.
Code:Any city or county •�
><$ which 1%issuance,
n Permit re construct,also,improve,demolish,w empodrsig ed amoctuto rnnn
to—rm
prior 0 In ilsiensrme,alua requires prevision
lersuch Con permit toicense aw(Chamem
F?Q Nu he is licensed pursuant 70lhe of Division
of Ne Comrxldrsnd Professions
(C Code)or Sq.Ft.Floor Area Valuation
y $ (commencing with Section and
the
basis for themegeBusiness ept on.Any vi Codo)or
.. Net he is exempt therefrom and dm bmu for the alleged exemption.Any violation of e.,e
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 S�6IPII"erO O Occupancy Type
not mom than fisc hundred dollars($500).
❑1,as owner of the properly,or my employees with wages an 0leirsole cmmpensadon,
will do thirwak.and theawaum u notintendcdmroQemdfwsale(Sec.70d4,Buainus Required Inspections
and Professions Code:The Comracter's License Law does not apply to e an owner of q P
property who builds or Im proves themon,end who does such work himself or through his
own employees,provided thatsuch improwmensssn nothas bled molpered forcele.If.
however,0e building m improvement is mid within ore year of compli u st.the owoer-
builder will have the burden of proving that be did not build or improve fee purpose of
cele.).
I.ae owner of the property,am exclusively contracting with licensed contractors to
connmet the projen(Sec.70x4,Business and Prnfessiam Code:)The Contractor's Li.
cense law docs not apply to an owner of property who builds or minnows domain.and
whoanlaca fmnuch pmjccts with
sconvmmr(s)lianud puravamPC in thin too: OFFICE COPY
Licenw Law.
❑1 em exempt under S �B k P,4QC CPthinrwon
/�� �pltd✓(a J Q
or ` f(
WORKER'S COMPENSATION DECLARA7ON
1 hereby affirm under penalty of perjury am of the following declamtlons:
I have and will maintain a Comficam of Consent self-inaum for WarkersComp�n-
.hen,as provided for by Section 3700 of the Tatem Code,fee the Performance of the
work for which this permit is Issued.
I have and will maintain Worke's Compensation Insurance,as required by Section
3700 of dm Labor Cade,for the performencc of the work fee which this permit is issad.
My Workers Compensation Insurance artier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXFMP 7ON FROM WORKERS'
COMPENSATION INSURANCE
(This suction need not be com plemd if the Permit is for one hundred dollen n I(1)
or Inas.)
1 at that in the performance of the work for which this permit is issued,I shall not
employ any person in my manorso as in become subject o the Workers'Compommict
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 foMwith comply with such provisions or this permit shall be deemed invoked.
r tiCONMUCfION LENDING AGENCY
(—t I hereby affirm that Nem is a construction lending agency for the Performance of
6Yi> the work for which this Permit is issued(Sce.3097,Civ.C.)
940 Lendces Name
PZ
Z Lenders Add.
U Q I certify that I have mad this application and sato that the chow information is
Da F comet.I agree in comply with all city and county ordinances and sale laws miming to
O U building convection,and hereby authortme representatives of this city to enter upon the
above-mentioned Property for hispecuon pappous
(We)agree to cents indemnify and kith harmless the City of Cupertino against
rU N in
granting of
expenses which may in ray way acerae against mid City
U z A APPLICANT
of the granting of This permit.WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG ATION'B, : SIO
Re-roofs
17 um',
rc of p tcmUContrscmr, Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ZWill the appfam m future building occupant store or handle hamrdous material
by the Cupertino Municipal Code,Cbapmr 9.12,and the Health and Safety
e.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yea )!,No
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
it hammus air contaminants as defined by the Bay Area Air Quality Manage mem all new materials for inspection.
District?
[I Yes �INo
I have mad the harandous material$mquimmcnts under Chapter 6.95 of the Collier.
nee Health,k$afctyCadc.Scctian 25N15.25533 and 25534.1 undersand that if the building
Jos not coil,how a mnm,that it is my remmucbility to mm,On w,cupent of On
mqutrcomise,hic muslbemmPriottoissuanaofaCeNficamof ry Signature of Applicant Date
W—� slu
O ncror autho i'reJ egem tate All roof coverings to be Class"B"or better