03060037 F11B7771
ITY OF CUPERTINO '�`� �°a` ""�'�^ '�
BUILDING DIVISION PERMIT INC
C ORACTOR4NF;ORMATION:
LDING ADDRESS: PERMITNOO 3 0 6 0 0 3 7
ROBINDELL WAYNER'S NAME: PERMIT I! 4/2 0 0 3
LANG YEE–HSIANG AND HSU SHAN
ONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
dg Zp LICENSED CONTRACTOR'S DECLARATION Job Description
�+ 1 hereby&flim mel I am licensed under p evlsiont of Chapter 9(Commencing p
¢ withS.ren?=)ofDivision 3ofthe Bund.and proposiumCode.and myIi".is ADD 300 SQ. FT. FBN�gL�
in full force and ef(e(L D
j n Z License Clete Lie.N
Dare CSDECL MAY 1 3 2004
z
ARCHITECTS DECLARATION
1 undersund my Pima shall W used u public records
3u.p Licensed Rufudanal 11 1 �1
OWNER-BUILDER
exempt
DECLARATION BUILDING
I hereby,IRm that I em exempt from the reamrsemra License Law for the
p O fallowing Fat(Section 1(13 L5,Business and Profcuions Code:Any city ar County
$ which requires a permit to construct,altar.Impro n.dcmnlish,or Farm any structure
prior to its issuance,also requires the applicant for Such Permit o file a signed auormal
C�<
that he is licensed pursuant to the provisions of me Contactors Li®nse Law(Chapter 9 Sq.Ft. Floor Area tion
eFt (commc.ing with Section 1000)of Division 3 of do Businessland Professions Cale)of
that he is exempt fherefrom and the basis for the alleged exemption.Any violation of
Section 1831.5 by any applicant for.perch subjects the applicants ro a civil Peaally.r er-U Occupancy T),pe
nut more men live hundred dollars(5500).
C]I.a owner of the property,or my employees with wages as their sale compensation,
will do the work and ue twctee is not Intended or offered farmle(S..7W,Business
and Professions Code:The Contactors License Law docs not apply to an owner of 102 - PIERS Required Inspections
propertywhobuildsorimprovthemen,endwho doessuchworkshimselforduoughhit 103 – UFER
own employee,provided that such improvements am notintended or offered for sale.if.
however.me Wilding.improvement is sold within..yeardandphom..me owner- 104 — REBAR
Wilder will have ft Interco of Proving that be did OFF Wild or improve f.purpose of itis — ANCHOR BOLTS
�t
f 1,a owner a(me pmPem..m.."b"'<Iy contracting with liensed.noaema to 106 _ SEWER & WATER
uuct ghep.jec(Sea10a4,Bamea add professional Code:)The Canommes U. 202 UNDERFLOOR PLUMBING
en Law does not apply to an owner of property who Wilda or Improv demon.and
who contacts for such projects with a contractor(s)licensed pursuant to the Commerce$ 203 - UNDERFLOOR MECHANICAL
License Law.
❑1amexempt Order See. Bk PC for thisreuon 204 - UNDERFLOOR FRAME
<6a,—,fD.te — O 205 — UNDERFLOOR INSULATION
One WORKER'S COMPENSATI J LARATIO 301 - ROUGH PLUMBING
Ihereby
armmunder penalty ofperjury one ofthe following dela.eaa: 302 - TUB & OR SHOWER
❑I he.and will realnal..Certificate of Consent I.self-inure for Wmimea Contra. 303 — ROUGH MECHANICAL
arab,as provided for by Scetion 3100 of the Labor Codi for the performance of the
work for which this permit is iu.d. 304 – ROUGH ELECTRICAL
❑I have and will maintain WoA¢rs Compensation Insurance.as required by Section 305 — FRAME
neo.fineLaWrCode.forthepeefomanmofmgweckforwhichthispermitisla.d. 306 – HOEDOWNS
My Workers Compacted..Insurance easier end Polity numb.,am:
Care PolicyN..: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS' 308 — SHEETROCK
COMPENSATION INSURANCE
(This seci.need Out he Completed light,permit isrorone huminsidollm(SI00) 309 — EXTERIOR LATH
.less) 310 - INTERIOR LATH
1 er,ify that in the performance of,he work for which this permit alarmed.I shell not 311 - SCRATCH COAT
employ any parent in any manner so u to become subject to the WOfkarr Compensation 313 — ROOF NAIL
Lows.(California.Dam
Applicant 501 - FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT:If.arm,making this Certificate of Exemption,you should
become subject m the Worsen]Compensation provisions of the labor Code.you must 502 - FINAL PLUMBING ENERGY
ZZ mcomply 503 - FINAL MECHANICAL ENERGY
o
CONSTRUCnON LENDING AGENCY 504 - FINAL BUILDING ENERGY
'[n (hereby affUm d,there is.construction lending agency for the performance of
IY rite wink for which this permit 4issued(S.,3.9'1,Civ.CJ 505 - FINAL ELECTRICAL
W C lander:Noma 506 – GAS TEST
Z lander'sAddres, –
U O 1 ardfy that I have mad this application and game the,ftshove informNun is 507 FINAL PLUMBING
ty F coma 1 agree m comply with all city and county.dim acl and sum law relm.g u 508 – FINAL MECHANICAL
OU Wilding construction.and herebyauthonm repreaenudv.f Oil city u enter upon the
WaWvcmentiomdproperty for inspection pugtoaes 09 FIN GRADE
(We)agree to save,indemnify and seep harmaa the City of Cupertino egaial 0 FIN
zq liabilitie,judgmenu.case and expenses which they in any way aicmeepialevd Ciry
U o� APPL CANT UNDERSTAin anumproof the N r I
AN'mILL LY WITH ALL NON-POINT Issued by:51 A WORKS Dale
SOURCE REG L NS. _ IO
Re-roofs
cum of Applican rc.r u rotor Dam
HAZARDOUS MATERIALS DISCLOSURE." Type of Roof
Wi110.
l me.pplicant.f future Wilding Occupant Stam or handle huardous material
u deB.d by the Cupertino Municipal Code,Chapter 9.12.and the Heald and Safety
f•bde.$.mom 25532ea>1 ...✓✓✓/// All roofs shall be inspected prior to any roofing material being installed.
❑Ym I�Nt�
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huaNms air contaminants u dalmal by me Bay Area Air Quality Management all new materials for inspection.
Disuial
❑Yet I4Nu
I have road de Wrardas materials requirements under Chapwr6.95 of the Califor-
mmlicalddk SefetyCode,Secdoa 25515,15533 and 25534.1 underund thelf the Wilding
ds nor cumndy have a cant,th a h an respoaihility to notify the Occupant of the
requirements which mug Wm or team of Occupancy Signature of Applicant Date
er ofaahanacd agent Dau All roof coverings to be Class "B"or better