04030039 CITY OF CUPERTINO '°'' _tRET
BUILDING DIVISION PERMITCONTRACORTNFQRMATI.QN
BUILDING ADDRESS: r 1E11ITN004030039
'711r9 PQRTT\TT)P.T.T. WV
19 ER'S NAME: PEiti ISSUE DATE
CHEN CHIH-CH
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTBNGINEER: 1 IN INFO
L B MECH
l�
>jO0 LICENSED CONTRACTOR'S DECLARATION
ly F Ihereby affirmthat lamlicensed underprovisions;ofchapter 9(commenting Job Description JUL 6 2004
aTj with Section 7")of Division Sof Ne Business and Professions Code.and my license is
< infull mroaunit affect. REMODEL--UPGRADE/NEW ROOF
5 ? License ClassContr D
ARCHITECTS DECLARATION n Dao: onBUILDING
'y$ I understand my plans alWl M used as public records
c Lleerrse0 Professional
OetNrm BUILDER DECLARATION
2 I hereby affirm on I em exempt from the Conincufa License Lew for the
OO followingnoon.Permit
a IIDL5,Busmanand Professional Ca de:Anycity nr county
In poor
uquirta•e.also mcnns thealar,improve,dcermitt rare a sig say structure
Fly in" to its lensed p,eluftto the thovisioont for men permitmfdes Law(Chapter
nnn
thumencinwit puuoantsothc provisions(if the Cammcelsnd Pral law(ChodICr9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)the
Division 3 of the Business and im.A.,ms Code)of
that M V exempt mcmfrom and the buss far Ne alleged exempdon.Any violation of
Section 7031.5 by any applicant fora permit subjects me applicant to a civil penalty of 3 921,15 1f cr,0 0 Occupancy e
m du
not more ave hundred doll.(M).
P y •Ty 7p
❑1,at owner of Ne property,or my employes with wages u their mile compensation,
will do the wm s end theaw.mre is nalinon ial ora@red for sale Occ.1051,Business
and Profcsaioru Code:The Conuumr's Llama Law does not apply in an owner of Required Inspections
property who builds or im proves memon,an d who does such work himself or through his
ownemployces.provided thin such improvements am not intended muttered for We.it,
however,me building or improwmmt is to within cam year of completion.Ne awmr-
builder will have site burden of proving dot he did not Wild or Improve for purport of
sale.).
1!]1,as owner of the property,am excluahody...Voting with licensed conuacmra be
comuum the project(See 1054,Business and Prefeadov Cade)The Comhom?a V.
care Lew does not apply b an mane of property who buildsor improves memo.,and,
who contracts for such projects with a connnor(O licensed pursuant in the Comracmfs
License Law.
❑I sur carrot, Sec. Bk PC for this mean
Data
0
WORKERS COMPENSX17IONTIECLARATION
1 hereby affirm under penalty,of perjury one of the following declarations:
❑1 have and will maintain s Cie ificnu of Consent to sel6inare for Wmkcr's Compen-
sarim,as,provided for by Section 3100 of the Labor Code,fm the performance of me
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3100 of the labor Code,far the pcAatmamo of me work for which this permit is issued.
My Worker's Compensation brsurenm artier and Policy number am:
Carder, Policy No.:
CERTIFICATE OF BXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
Tits sectironeed nm be completed lithe permit is fmon.hundred dallan(SIM)
or Imo.)
1 certify that In the performance of use.,it far which this Permit is Wood,I shall not
employ any poison in any manner an as in M.comcabject to IM Workers'Compcaation
laws of California.Dam
Applian
NOTICE TO APPLICANT:IL spot making this Certificate of Exemption,you should
become abject in me Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provionru or this permit 0,11 be named revoked.
'Zrte`., CONSIBUCTION LENDING AGENCY ,
(-+ Ihemhy affirm that them iso construction lending agency for the Performancea
tYi r: the work for which this permit is issued(Sec,3091,Cih,C.)
Q Lendcr'a Namc
r7. z Le der's Address
U C 1 certify that 1 have mad this application and mo the the above Womutiun V
ig, s'.1 correct I agree to comply with all city and county ordinances and a=laws relating to
O building convection.and hereby authorim representatives of this city to enter upon me
W above-mentioned property for inspection purports
13. (Wo)agree to save,indemnify and kap harmless the City of Cupcnino against
h liabilities,Judgments.costs and expenses which may in any myacom against said City
U z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL NON-POINT Issued by:3 �du Date
OURCE REGULATIONS, 0
L14 Re-roofs
i8 arc pP,4
uT75.1bacluead
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant more or handle huudous material
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes �}Nu
Will the applicant or fuere Wilding occupant use cquipmant or acviaa which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardnn air cmuminans a&fend by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea l6No
I have rend the hmsmnua materials requircmcn s under Chapter 6.95 ofthe Califoo
nu liralth h SafetyCode,Sodom 25505,25533 and 25534.1 understand con if the Wilding r/� /�( s
does not cnmmly ham•cent,mat it s my maponibility to notify the Wcopmo of the y/t
mqui res must con p oro issumcc of a ce 'fcao upanry. r�0/
r, e G S, �6 (� gnatur3 a of Applicant Date
owner ar mrima egret I Dam All roof coverings to be Class"B"or better