06030021 CITY OF CUPERTINO •' e e "�•s'ba'-Fim � d ;
BUILDING DIVISION PER T CONTRACTOR TN�FOR R ON
. .S+.ra
BUILDING ADDRESS: PERMIT NO,06030021
22434 RIVERSIDE DR
OWNER'S NAME: PERMIT m"DATE
ANDY CHENG _ Q3/06/2006
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
j00 LICENSED CONTRACTOR'S DECLARATION
LwF I hereby affirm that 1 am licensed under provixions of Chapter 9(commencing Job Description
SZ3 with Section 7(X)0)of Division 3 of Ne Business and Professions Code.and my license is
.'=y mlberomcandcRen. REMODEL-LOWER/MAIN LEVELS/MODIFIED WALLS/ELECTR
a 12? License Class Lic.p
n- mm Contract., THROUGHOUT/FURNACE/WATER HEATER/INTERIOR DOORS
'qq ARCHITECTS DECLARATION GARAGE DOOR/FRONT DOOR/3 WINDOWS
$U I undersand my plans snag be used u public memos
d
S G Licensed Pnafcssi.nal
R1OWNER-BUILDERDECLARATION
N I hereby affirm but I am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5,Business and Pmfnsium Code:Any city.,county
<m i4i which requires a permit to consumer.Slier,improve,demoikeh.or repair any structure
semi prior In its issuance.also requires lbeapplitant for such Permit o File a Signed statement
iGthat he is licensed pursuant to the previsions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
yl- (comm eneingwith Section](XW)ofDivision 3oftheBusiness and ProfessionsCodelor $65000
,59 div he u exempt rivers m and the basis for the alleged essmplion.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not more than in hundred dollars(B5W). P Y Type
Q 1,as owner of the property,or my employca with wages as their sole compensation,
will.do the work and the structure is notinunticd mortared for sale(Sees.7044,Business
and Professions Code:The Committees Lice=law dm not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself orthrough his
own employees,provided that such improvements are not intended oroRered(orsale.If,
however,We building or improvement is sold within one year of completion.Ne owner-
builder will have the burden.f proving that he did not Wild or Improve for purpose of
sale.) y.,;
/ YY 1 1 {
co 1,as owner of the propene,.B=elusively contracting g with:)Thai Contractor's mnuacmrs m 1 ea „ rt /r C( K y;♦
cmureathees not (Sec.s in Busmenandrrywho Wi Cade:)The .Lid 'i,1 k. TGiA
cense Ism does not apply m an owner of pmpesy who sedds M Improves thereon and
who consactsfor avch projects wit acanOazmr(s)bcensed pursuant so the Contractors
❑I am exempt under Sec. B&P C for this..on
Owner Dam
-WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury on of the following declarations: Illiii■ _
❑I have and willmaintainfbSection
37Mcam of me Lat tobor
solf-Code.for a Performance
ce Or a l � t
Compen-
sation,az nd will for h Sa Cen6 3100 of the labor Cade,far the ,arless cc of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section .
37W of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are: {9t) ajRP
JUN 2
Cartier. P.IiNY O ,
CERTIFlCATE OFCOMPE COMPENSATION
NFRAN WORKE0.S' Bull
I
COMPENSATION INSURANCE 1L
(This sermon need not he completed if the pc,mil is forone hundred dollars(BIW) AG
m less)
1 certify Nm in the performance of the work for which this permit is issued,I small not
employ any crun in any manners.a9 W Mq�me subjcel to the Workcri Compensation
Laws of California.Date /<
Applicant n
iz
NOTICE TO APPLICANT:If.after making this nI i ac of Exemption,you should
bre ne subjoin to the Worker's Compensation previsions of the labor Cndc,you must
.JO forthwith comply with such provisions or this pemtil shall he deemed invoked.
Z" CONSTRUCTION LENDING AGENCY
[-+� I Wroby affirm that there is a eonsuuminn lendingSent for the '
agency perlunnantt of
0$ the s:mk fur which this ptmtil is issued(Sec.J09],Civ.C.)
fat0 t<nticr's Add
Ictitler's dtlmss
Name
E z
E
V Q I certify Nal I have read this city
and county
nM sum then the above information is -
0 H
COMCL 1 agree to comply with all city and county ordinances and sum laws r upon t e
p U abovengconstruction,tioneand herebyoins authonp rcprescmativcs of this city mcnmr sport Inc
r W
above-mentioned agree to
for -fify an keep
(We)agree is save,indemnify and keep harmless the City of Cupertino against
o-F.tZ in
ments,rosning expenses which may inany way accrue againntsaidCity
(„)z m c.nuyucncc of the granting of this permit.
r-a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 13- Gni!
SOURCE REGUL_A, IT!,O�� y,,
i
Slgnatlt(of ApplmanUC.nI to Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hrtancous mammal
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code Section 25532(a)+ All roofs shall be inspected prior to any roofing material being installed.
Yea (�u
Will the applicant, (mu�buito nB—up or use eyuiPmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haeardnus air cnnmminanL defined by the Bay Arca Air Quality Management all new materials for inspection.
Dimrmn
]Yes No
1 have read the hmardous materials requirements under Chapter 6.95 mine Califon
.is Health&Sd.IYCode,ScNms 25505.25533 and]5534.1 undcmusul Nat if the building
docs not runt I ha tenant that it is my resprodol0y m n.Wl'y IM mcu,ou nf,w
myu'rcmcnts benteIpriortocominceofaCc.r,.wof/afupanry. Signature of Applicant Date
�" E/�`
Owner m awM1.rirad Dam
All roof coverings to be Class "B" or better
aFcnl
-' _- CITY OF CUPERTIN
CITY OF PERMIT APPLICATION F�RM
CUPERTINO
APN # J � Date:
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#: pp
3/rt;-6g73
Contractor: License#:
Contact:��� Phone:g2r3q�-ho973 Cupertino Business License#:
m GkOFax:
Building Permit Info: y & 'Ap A��1, wpm„ d
0 / 'YiLRJ(n'�''Cn�ieri� .- SA-V� cjr�.r
BldgElect Plumb �f Mech
Job Description: � LIAW14 � s /�
Residential X • r ' -k,0'%5Vbinmercial ❑ r`7i1" 9
Sq.Ft. Floor Area: C . '^n' q.Ft.:
C dluurgS~ dwo �, t OEcy r,
Cost ofProiect: /�-000, Occupancv Gror-
Type of Construction: Please check this box if the project is a
second-story addition: ❑
roject Size: Standard Q Large ❑ Major ❑
uant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BB0ILER2 Boiler> 100K to 500K Btu MECHANICAL
BB.OILER3. Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to L75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
*CITY OF CUPERTIN r
'1► CU C ODFINO PERMIT APPLICATION FIRM
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMIvIM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTD E Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
MIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAMHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation ofFumace MECHANICAL
BRBMFURNOV Relo Furnace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMEINHOOD Installation of Hood MECHANICAL
BRENUvaSC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
13REWOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power DeAce/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
/ BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Ap liance ELECTRICAL
2 of 3
AY OF CUPERTINO �-
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Grou •
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMYENFAN Vent Fan Single Duct MECHANICAL
BREMYENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special 1nspection BUILDING
BSVvBI Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEM PPERMZ Temporary Bldg Permit BUILDING
BTEMPSVCS T=p Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
D ELECTRIC Electrical sq foot ELECTRICAL
EPERAMFEE Elec Permit Issuance ELECTRICAL
MPEP FEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Commel Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
•
3of3
0
CITY OF CUPERTINO
•tn 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35602004 .00
DATE ISSUED. . . . . . . : 03/06/2006
RECEIPT #. . . . . . . . . : 33457
REFERENCE ID # . . . : 06030021
i
SITE ADDRESS . . . . . : 22434 RIVERSIDE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ANDY CHENG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3959
RECEIVED FROM . . . . : ANDY CHENG
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
_____________ __________ __________ __________
BPERMFEE VALUATION 65,000.00 1274 .40 0.00 1274.40 0.00
BPLANCHK PERMIT FEE 1,274 .40 1700.69 0.00 1700.69 0.00
BPWHEATER PER HEATER 1.00 10.79 0.00 10.79 0.00
BREMHEAT NO OF HEATERS 1.00 7.02 0.00 7.02 0. 00
BENERGY PERMIT FEE 1,274.40 611.71 0.00 611.71 0.00
BREMINHOOD NO UNITS 1.00 10.26 0.00 10.26 0.00
PPERMITFEE FLAT RATE 1.00 '38.37 0.00 38.37 0.00
BREMREPALT NO UNITS 1.00 14 .31 0.00 14.31 0. 00
BSEISMICRE VALUATION 65, 000.00 6.50 0.00 6.50 0.00
ELECTRIC SQUARE FEET 1, 804 .00 144 .32 0.00 144.32 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
MPERMITFEE FLAT RATE 1.00 38.37 ,0.00 38.37 0.00
TOTAL PERMIT 3895.11 0.00 3895.11 0.00
METHOD OF PAYMENT AMOUNT NUMBER
__________________
OTHER 3895.11 VISA
TOTAL RECEIPT 3895.11
* ER-BUILDER VERIFICAWN
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
• A. All the work authorized by this permit
B. A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. `All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
t3G Gil V[rtCii
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side
Property Owner's Signature: ?� Date:
Job Address: ? tf3y ��v ert�o(e �/Yt� Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.
M
City of Cupertino Building Department
CITY OF 10300 Torre Avenue*
CU PERTINO Phone: (408)777-3228
Dear Property Owner.
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work if your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license numbk6-i on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors,then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation•
contributions.
There may be financial risks for you if you do'not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and materia_ 1
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your comi nunity or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification'form so that we can confirm that
you are aware of these matters. The building permit will not be'issued uritil the-verification is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed on Recycled Paper
MAY-16-2006 07:55 MARK THOMAS CUP 4082535173 P.01/01
- .RQ~`moo SAN I r4#.,, /
DISTRICT MANAGER-ENGINEER a ca BOARD OF DIRECTORS
MARK THOMAS&COMPANY,INC. " WILLIAM A.BOSWORTH
DAVID E.ROSS DR,JOSEPH F.BROWN
JOHN M.GATTO
DISTRICTCOUNSEL Fj` y6
l�B(I S NEO ��' CURTIS B.HARRISON
ATKINSON■FARASYN,LLP WENDELL H.KERR.JR.
HAROLD S.TOPPEL20833 STEVENS CREEK BOULEVARD,SUITE 104
J CUPERTTNO,CALIFORNIA 950142154
(408)25&7071 PHONE No (408)2535173 FAX
File: CuSD—MOP
Building Dept.—Cupertino
City of Cupertino
Attn.: Building Department
10300 Tone Ave.
Cupertino, CA 95014-3202
Subject: Residential Remodel/Addition
Name:Cheng Residence
Address: 22434 Riverside Drive
APN: 356-02-004 O G 03 0'.) 2_1
Permit No.06020010
■ Videotape and Property Line Cleanout inspected.
No additional conditions/requirements by the District.
Inspector: Tony Soares/George Santos........'
Date:...05-16 2006..... ............. Sanitary Sewer Location•
cc: Property owner
*Backflow inspected.
SUPPLYING SANITARY SEWERAGE S6RYIGES For: CITY Of CUR6RTIND, PORTIONS OF TNT CITIES OP SARAT06A,SUNNYVALE, Los A110A AND SURROUNDING UNINCORPORATED AREAS
www.Gupertino5ooitorydistact.Gom
TOTAL P.01
• Andy Cheng
22434 Riverside Drive
Cupertino,CA 95014
What we have done:
1. Replaced old water pipes in house with copper,
2. Replaced some old drain with PVC,
3. Installed new recess lighting,
4. Replaced damaged wood beams,ply woods,and sheet rocks,
5. Removed crumb bread ceiling,
6. Prepared walls for new texture and painting,
7. Stripped old Floor for new hard wood and carpet for entire house,
8. Removed kitchen cabinets,fixtures,
9. Removed bathroom fixtures,
10. Removed all interior doors for replacement.
Plan to do:
I. Replace front door with double door,
2. Replace windows: replace an existing 120"x58" window with bow window, replace an
existing 71"x4T'window with bay window,replace a 60"x48"window,
3. Replace all interior doors,
• 4. Replace fumace,
5. Replace heater,
6. Replace garage door
7. Replace stair rails
8. Install new kitchen,
9. Install new bathrooms,
10. Some new lighting,
11. Remove sheet rock for inspection. MAR 0 6 2p06
i
•
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5010 6 7Kitchen
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KITCHEN
n
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8876
LIVING
31'-3"x22'-6"
DINING
•
6'-6 112" 5'-V' 6-0" 2'-2 3/4"
5640 8837
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n KITCHEN ^
-------------
6876 J
O DINING LIVING
31'-3"x22'{"
2468
Master
MASTER BATH Bath
11'-2" x 10'-11" cV
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11'-2 1/2"
2468
0
MASTER BATH
11'-2"x 10'-11"
N
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5040
11'-2 1/2"
• CLOSET
6'-10"x 2'-0"
Hall Bath
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STORAGE
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0
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BATH
N
-10" x 8'-9"
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'-10" x 3'-
7 -- 0
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BATH
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0
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3rd Bath
0
BATH
'-5" x 7'-6'
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2068
71-11/211
0
BATH
4'-5" x T 6" -
00
2068
7'-1 1/2" - -�
•
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT£OWINFORMATION
BUILDING ADDRESS: PERMIT N0 0 6 0 3 0 0 21
22434 RIVERSIDE DR
OWNER'S NAME: PERMIT ISSUE DATE
ANDY CHENG 03/06/2006
RIME: SANITARY N0. CONTROL NO.
NNALED
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
IIID 2 0 [uuu o 0 0 0
upp LICENSED CONTRACTOR'S DECLARATION CON Job Description
uu 1 Mrtby affirm that 1 am limned under provisions of Ccide. 9(commencing P
b with section 7000)of Division 3af NC Businw and Pro(etiuro Codc.aM myliccvc is
n n. in full form and affect. REMO%"C
ELS/MODIFIED WALLS/ELECTR
i�E License Class Lic.Is
g Dam ARCHITECTSDECLARATION THRO TER HEATER/INTERIOR DOORS
@ u IunderwndmyplansshallWtracdasp.hire mcmdx GARAGE DOOR/FRONT DOOR/3 WINDOWS
sap f Licensed Professional
5 OWNER-BUILDER DECLARATION
<� I hereby affirm that 1 em exempt from Be Comracmr's License law for the
D o following mason.(Section 703 1.3,Business and Profaasimn Cade:Any city or County
K$(L which mi uires a permit to construct, lw,.impmw.demJixR nr hepair any svucmre
prior to its issMnce,alaemquimatheapplieant for Such permit to Ele augned audement
i<
that he is licensed pursuaouo the provisions of Be Contractor's Umnse Law(Chapter 9 Sq.Ft.Floor Area Valuation
yF$ (commencing with Section]00(BofDivision 3orthe Business and Proressio.Codc)or $65000
.•
that he u exempt Innermost anal the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicsmfor a permit subjects the applicant to a civil amdiy of ppN Number OCCU
not mom Nan live Occupancy ve hundred dollars(M). P Y Type
El I,as owner of to property,or my amPloyma with wages as Bear sole compensation.
will do the work,and the structure is not intended or offered for sok(Sec.]044,Business 356e2eezt . Ex)
and Professions Coe:The Convectors Llceve Taw doer not apply an in owner of Required Inspections
property who ban sits or improwa Nemon,and who does such work himsel f enthrough his
own employees.provided that such improwmenu ire not intended oroffered forsak.If, I
however,the building or improvement is sold within one year of completion,the owner-
budder will have th,buNen of pmving that he did not build or improv for puryoe of /'1
sale.).
❑1.as owner of the proper am exclusively convecting with licensed convectors to
consvuct to project(Sec.7044.Business and Profemons Code)The Convacmri Li- •� s s IC tEl,,x3j
cave law doe not apply in an ower of pmpenYwho builds or Improves themon,and
who convects for aucM1 pmlecu with acanuacmKs)licensed pursuant¢Ne Convenors J `
License law.
❑nem tempt under See B&P C for this
Owner ' Data
awORKER'S COMPENSATION DECLARATION
I hembY aRnn under penalty of perjury ane of Be following dedurtiov: �/` USI///�j`'/�
)haw and will maintain a Certificate of Covent to self-insure for Workers Compen- /` J
.don,as provided fm by Section 37M of the labor Code,for de,performance of the �J
work for which this permit is issued.
❑1 have and will maintain Worker's Compevation Insurance,as required by Section
3700 of Be labor Code.for the performance arrive work for which this Permit is Issued.
My Workers Compevauon Insurance artier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rds section need not hecomplemJ BBB permit is form=hundred dallers(SIM)
or less.)
1 certify Nm in the performance of the work for which this permit is issued,I shall not
employ any person in any mam 'W he me subjectto tewmocia ComvN
pcmn
Laws of California.Data J
Applicant
NOTICE TO APPLICANT:If.after making Nuc I¢ate of Exemption,you should
hosanna subject m Be Workers Compensation provisions of Ne labor Code,you muse
.JO foMwiN comply with such prelude.or this .it Ali]W dcemcd hawked.
Z CONSTRUCTION LENDING AGENCY
[-+ l hereby affirm Nat them iso mnsuuctinn kndingagcvy herdic pefornan.of
rt. Ne work for which this permit is issued(Sec.3097,Civ.C.)
[410 Lenders Name
z Lender's Address
U 0 1 certify Nn I have mad this application and sum that Ne also.information is
D. F correct.1 agree to comply with all city and county ordinances and slate laws misting in
O V building conssuction,and hereby amhorire mpmsenmies of Nis city to enter upon Nc
alwve mentioned properly for inspection pur,adea
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
.F.I h Iiabili0a,judgments,cosuandeapevv which may in anyway 20sWillomMsaid Ctry
V Z in consequence of the granting of this Permit. /
^` APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date "��•
SOURCE REGULATI
Re-roofs
99—gn�mf AppM1 MM1Chm%d5W Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building temporal pore Mhandle hvandons mamriJ
as defoml by Be Cupertino Mi nidpal Code,Chapter 9.13.and the Health and Safety
Cale,Dyes 35532(a)? All roofs shall be inspected prior to any roofing material being installed,
Ya �Nu
Will thea limM err f u baildin cert If a roof is installed without first obtainingan inspection,I agree to remove
np g pare use equipment or devices which P
emit hazardous air conuminanL as dofincd by the Bay Area Air Quality Management all new materials for inspection.
Disuicd?
❑Ya Nu
I have mad the hovrdcus materials requirements under Chapter 695 of fix Califor-
nia Health&Safety Code,Smuov 25505.25533 and 25534.1 andcrsuM that if Ne building
dao not curtcnty- a moan,Nal it is my responsibility to notify the occupant of the
hagtimments beeretpnnrtoisstanmnracenifiamofOcp�pancy.` Signature of Applicant Date
/� //
Owner or avthonmd agent IN— All roof coverings to be Class "B"or better y