03110142CITY OF CUPEW11N0
- BUILDING DIVISION PERMIT�,CONTRACT,OR
INFORMATION .,.;
euILDING ADDRESS:
EUGENE LEW
PERMIT NOO 3110142
ER'S NAME:
PERMIT ISSUE DATE
GENE LEW
11/24/2003
E:
SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 E Q
LICENSED CONTRACTOR'S DECLARATION
Job Description
visns of Chapter 9 (commencing
1 Mreby affirm the, I am licensed under ptoio
p
with Section 7M)) of Division 3 of the Business and Professions Code. and my license is
in btR fora and offset.
LicenseClass Lk.0Dam
KI?FChIEI j�
TS DELLAs.hall ECTS DECLARATION
I understand my plain shall he used as Public rcaNs
nODEL
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tl
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that am exempt from the Contmcmes License Law for the
f !ll
following mason. (Section 7031.5, Business and Professions Cale: Any city or county
LLLIII
which acquires a permit to construct. alma, impmw, demolish. or repair any moon¢
$6000
prior In its issuance, also "or= the applicant for such Permit to... - a signed nammem
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 70N) of Division 3 of the Business and Professions Code) or
that M Is exempt IMrefrom and IM bub for the alleged exemption. Any violation of
Section TB31.5 by any appli.nl for a permit subjects the applicant to a civil Penalty of
pp �n1
3 dA®P3�i379er 0 0
OGGa
Occupancy Type
not mine Nan five hundred dollars (S500).
❑ 1. as, owner of the property, or my employees with wag. u their sole compensation,
intended draw dosacta(gee, toad,Business
will Pr Nework. endo: he Contractors
and ons Code: The Conuacmrs Liana Law does apply to owner of
Required Inspections
property or rt
puntop whobuildsorimpmt daresuchwork himselformmuge his
ownemployers,provided suthereon,antlwho
however, me building or improvement is sato within one year of completion, the owner-
provehImprowmenmarcnotintendedmoRered the owner.
,
builder
builder will have the WNcn of proving that he did not build or Improve for pury.e of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors In
construct the project (Sec. 70x4, Business and Professions Code:) The Contractor's Li.
cadre law does not apply to an owner of property who builds or improms demand, and
who contracts for such pmjecm with a conuactor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under See. . B & P C for Chia rc on
�, I
-UCTeW�LC.'L,� It
r Dam L✓b
WORKER'S COMPENSATION O • ATION
I hmeby afpmt under penally of perjury am of the following declarations:
hove end will maintain a Ccnif.te of Consent to self-insum for WorkersCompen-
ution, u provided for by Section 3700 of the Mbar Code. for the petfotmanec of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insuance, u required by Section
37M of me labor ewe, far the performance of the work for which this Permit is issued.
My Workers Compensation Insu.m:e.mer and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
OTisseclion need not becompmed if the Permit is for one hundred dollars ($101)
or Imo.)
I ce ify mel in the performanee of the work for which this Permit is issued, ) shall not
employ any person in any manner an as to become subject to the Worberi Compensation
Laws of C.Harei s. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Worker's Conformal provisions of the latter Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I Washy affirm mat mere is construction lending agency for dm performance of
the work for which this Permit is issued (Sec. 3097. Civ. C.)
Undoes Name
Lender's Address
I certify, that 1 have read this application and We that 0m all information is
correct I agree to comply with all city and county on inanas and suds laws reining m
building combustion, and hereby authome representatives of this city to cover upon the
above-memlodmd property for inspection purpowhichY1.
(we) agree to save, indemnify and keep humless the City of Cupertino against
lie expenses which may in any way ¢crus against said City
consequence of the
in consequence of the greening of this permit.
LICA DERSTANDS ANp-WILL COMPLY WITH ALL NON -PO NT
11/
Issued by: Date
(
RCER UL TIONS//
�
l
Re -roofs
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ta
sere MrApplicanbC mrecmrDaHA
ARDOUS MATERIALS DISCLOSURE
Type Of ROOF
WlllmeappliemL rfulure building occupant store orhandk omoodum materil
fined by the Cupertino Municipal Code, Chapter9.13, and the Hearth and Safety
;L,ict?
Section 355334/7
�Y.Win
All roofs shall be inspected prior to any roofing material being installed.
future
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or building occupant use equipment err devices which
ado. air anmminan���///s u dmOned by the Bay Area Air Quality Management
all new materials for inspection.
❑Yes ,jy No
I hive mad the hmaNmas materials r quimmenm under Chapter 6.95 of IM Califor.
nia Health At Safety Code. Sx6ons 25505, 35533 and 75534.1 understand that ifthe building
does not currently hew a tenant, that it is my rc mibility to and I be amupant of me
mquimmcnmwhian ewlonIm�ie=roanort Ce mamorot cy.
Signature of Applicant Date
d AFL ro
All roof coverings to be Class "B" or better
Own aur amhorircJ agent ,m