06060251CITY OF CUPERTINO+(;�`Y^�
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BUILDING DIVISION PERMITC�QIZ
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BUILDING ADDRESS:
JANE CHUEH
PERMIT NO. 06060251
22565 SALEM AV
OWNER'S NAME:
PERMIT ISSUE DATE
JANE CHUEH
09/14/2006
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMITINFO
BLDO ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 thereby affirm that I am llenmd under provisions of Chapter 9 (commencing
with Section 7") of Division J of du: Business and Pralcuu e,Cada and my liceose is
in full fallen AM9fma
INTERIOR REMODEL OF KITCHEN, MASTER BATH, HALL
License Class
Data Contractor
BATHROOM & POWDER. MINOR STRUCTURAL. NEW WINDOW
ARCHITECTS DECLARATION
AT KITCHEN LOCAL.
1 understand my plans shall hos used As public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby on)rm that 1 am exempt from the Conuacmr's License Law for the
following moron. (Section 703 1.5, Business and Profeasine Code: Any city or county
which roquirds a permit in conelNe . altar, Improve, demolish. or repair my structure
prior m its issuance, also require the applicant for such permit to rile asigod summent
Lim= Law(chapter 9
Sq. Ft. Floor Area
Valuation
that he is iensed pursuant intim provialmm ofdsc Con=WeS
(commencing with Section 7000) of Division 3 of Ne ausirtess and Professions Cade) or
$50000
the he Is emmPt therefrom and Use basis for the alleged exemption. Any violation of
APN Number Occupancy Type
Section 7031.5 by any Applicator for a permit subjects the aPPlicmt in a civil penalty of
not mom than five bundrd dollars (SSW).
❑ I, at owner of die ryapeny,mmy empbyees wits vngesuthe'v macmnpensstian,
Will An thework.and the$Moore ams)mmnded araQered forssm(Sec. TONT, eusircu
- Required Inspections
nsr P
Law dens apply In an awteof
and Prolamines Code The Conlranmh Limade e ro
q
property who builds ar i m proses thereon. and who does such wart him m f ar tiaaugh his
own employees, pro added hot such improvements are oat Intended oroRerest foreale B.
-
however. And building or Improvement Is mid within arc your ofcarnpatims, the aw ms
builder will have the burden of proving Nat he did not build ar improve for purpose of
role.).
, As mvmr of the property, am exclusively convening with licensed conuxclom m
co tmct the pmjecl (Sec.704a, Bohm eve Professiam Cade:) The Conuaemfa U -
mese law doe nol.pply man owner of pcoma Iy who builds or improses thercon, rod.
who convects for such pm*%with a contractor(s) licensed pursuant he the COntnctor's
Licence Law.
I.exam//pt under See. B k P C for this moan
1
neTy w. -W t /(Dau
RK R'S COM •NSATION DECLA TION
I hereby affirm under penalty of perjury con of dm following decelerations:
❑ I h.ve and will maintain aCeNaeem of Cortmnt m self -insure far Warmer Cumpen.
sation, As provided for by Section 3700 of the labor Crude. for Ne perfarmance of Re
work for which this permit is Issued.
❑ 1 have and will mountain Worknes Campeosation Insurance, es required by Section
3700.f the labor Cade. for the performance of the vert far which this permit Is Issued.
My Worker's Compensation Insurance eamier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rho saAan need sur bu mosplemd if de permit is Income hundrddallam (SI W)
or len)
1 certify out in the performance of the work far which this Permit is issued. I shall not
twthe Workers' Compensation
IT
m I an person ince manucrm been a t,,'
�'
Laois of CamiA. Date ' 1�i L
ApPllen(� �rrn�� -
NOTICE T�LI A : If. after making this Cestiacale of Esemption, you should
became subject in the Worker's Compensation provisions of the Labor Code, you most
' forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hominy that them a c 3 lending agency for @c performance of
this s d (Sec.
' theLe work fur which itis permit ts issued (Sec. JW7. Civ. CJ
which
Lender's Name
l<ndera Addrtss
I certify that I have read this application and sum Net Ne above infomsation Is
' correct. l agree to comply with all city and county oNmareas and sum laws relating in
building convection, and hereby amhmiae repmsenumi,cs of this city to color upon the
for inspection
above-mentioned propcny purposes.
(We) agree to save, indemnify and keep harmless am City of Cupcmno against
liabilides,judgments. costs and expanses which may in my way accme against mid City
in consequence of the granting of this Formal.
&
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
REGU 0 S.
_MCI,
Re -roofs
Type of Roof
S' eaturca pp enVConuactor em
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ottuPmtsmm Or bandit hesardoos material
As Abroad by the Camara. MuniciW I Code. Chapter 9.11. and tht Health and Safety
adc. Sttdon 15531(a)1nn
All roofs shall be inspected prior to any roofing material being installed.
V❑Yea �Na
If a roof is installed without first obtaining an inspection, I agree to remove
`�—Will tlm applicant or ion, building Occupant um equipment or devices which
emit Maardo s air canaminan , a deamd by the Bay Ama Air Quality Management
all new materials for inspection.
Dualn7
Cl Yon ®No
I have mad the haaaNnus materials mquim rmas under Chapter 6.95 orthe Califam
na Healu A Safely Code, Sections 255)5, 35573 and 73534.1 understand tau ifthe building
doesnot cumenlly havea con 4 dml II ie my tespamihiiny In notify the Occupant or the
coqeats whkh a elpdarmiauancenfaccrdacaa.f0m
Signature of Applicant Date
All roof coverings to be Class "B" or better
Ownerarmmorimdagtm D m