08010056 CITY OF CUPERTINO a .x- �yp
BUILDING DIVISION PERNIIT CONTRA.CTOR5 NF6 t 10N ''�'• .
ts�,kvh: ear-.. '-i'Yu`au}A•",bw�k.nA $E` er
BUILDING ADDRESS: PERMIT NO.
21861 SAN FERNANDO AVE HUANG, SHAY JAN 08010056
OWNER'S NAME: PERMIT ISSUE DAM
HUANG, SHAY JAN 21861 SAN FERNANDO AVE 01/10/2008
PHONE: SANITARY NO. CONTROL NO,
HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
Ow'zLICENSED CONTRACTOR'S DECLARATION O O O O
a 1 hereby afnam duo I am ticsnscd under pmvidoes of Chapter 9(commencing Job Description
�i with Section 7MQ)ofDoiaim 3of0u Business and Profeasom Code,aM my licc.is RMDL KITCHN, BATH NON-STRUCTL, LIGHNG IN LV & BDRM
<Bi in full fora and affect
License Class Lic.g
c t„ Doe Cpmlmmm
;q ARCHITECTS DECLARATION
a 1 understand my plans shall he used u public records
o.
y Licensed Prefnumml
OWNER-BUILDER mDECLARATION
Z< I hereby.lion oto I am exempt from gat Cssions o License Law far tie
1❑o following moon.(Section 703 1.5, t,aluusa and ow.dem li Code:Any oily at County
$ which mqulrea a issuance.permit aim re anuruet attic improve,demnlW,or mpoig any Iwmum
Zy priarb.lcnsedpulanitto the
the applicant nl forthe Commsuch oners
leoessele a AW(Chaptened cnl
C`< NuheBlia�JpSectio 70M)ofDisimu 3ofthe mrnBusinessanaruclaw(CNpur9 Sq.Ft. Floor Area Valuation
s (emnas 6 ia,exempt
pt tSatirom and the
Div h,far the s oped cu and Prom.Any rat Code)Cohn of $2000
that Section
W esempl thercfmm and oe aper for the alleged...mpgart Any vinlatian of
not tom Ones by any
undredianars(MMpermit rvbjau ua:.pplicantmadMlpwlrr of Number Occupancy Type
im,mamthxnwhandmadNlemtSlOBA 35715042 .'
❑L o thewrL and the
stru otimm cad or offmgea u ue'vsel. 044,Busagan.
will dooewoh.andoehac,ure is notinLia oraw dofarsalepplyuUH,wnaoa
and eny who
Cade:The Canuaman.Llceme Law dors nal apply lf an owns,is Required Inspections
man emywhobuilds orImpmwsh impatoar who timesantwart ear aelfar through his
awn wr.the
eWipmWded that suchtau is semens,ere not Intendedo mphat red fiersale.the own R.
Wilder.the building or impmwmcnt usold within oto year of completion,theowner.
of
Wilder M4 haw the hurtles of paving Nat he tlM not build m Improve for purpose of
sale.).
❑1,a owner of the property am eachomly conouamil with n¢aed conuummrs to
coestmct the pmjea(Sec 1011.Business and PmreWmrs Cade:)The Contractors U.
come Law does not apply M an owner of Pm coy who Wilds or hormones thenen,and,
wW contncu for ouch pajeeu with acantractortUliceruedpursuanttothe Ommu e.
Luense Law. -
❑lamaemptunerSec .B is P C far Oil maxis
Owner Data
WORT 'S COMPENSATIOND RATION
I hereby affirm under penalty of Perjury as of following decluuloce
❑I haw anti will maintain a Ccrtifsau of Comem ladiesum far Wmarm Campen-
ion,u pmvitictl for by Sagan 7100 of the Labor Code,far the peRonnenco of the
h for whi<nt thio pmol,ts isaad.
I h.and will maintain Workers Compensation Insurance,as regaized by Section
3T(ID of im L.0m Code.Ito the Performance of the want for which this permit is Wood '
My Workers Compensation Ieauruvs artier and Policy number are:
CaoW, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ih4xcgan need not W coseplc ml if oe permit is fmonc hundred dollars(Skil)
or lass)
I certify dao,In Ne performance of the work fm which this permit is issued.I shall not
employ any person in any meaner an as to Woman subject o the Workers'CompmosAti m
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,afar making this Ccninau of Exemption,you should
become abject to the Wohars Compauugan pmvisioas of tho Iebm Code you muss
.JO foMWlth comply with such provisions,or this permit shall W devem!cooked.
Z y CONSTRUCTION LENDINGAGENCY
[—t I heseby afinn this Burt is a mxcmccon lending agency for the Performance:of
E
the war,for which This permit is Issued(Sec.3097,Civ.C.)
127 Q Lemice,Nurse
z Lenders Address
U Q I con fy that I haw mad this application and sou that the show information is
com:ci.I yme to comply with all city and county on intoes and mu laws misting to
O building consomedon.and hereby authorize representatives of this city to enter upon tie
477 show-mentioned pmpeny for impemian purposes.
py (We)agree to taw,indemnify and kap harmless gat City of Cupertino against
,,,• to liabilities.judgments,costs and expensca which may In any way risme agaimuaidCity
U'z in conseguenec of the granting of this Permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PoINT Issued by: Date
TA NS
SOURCE REGU , , 17(poo
Re roofs
Siauure ear AppliranuCon Data
HATAR S MATERIALS DISCL RE Type Of Roof
Wlll the applicamm(as building maPanUmre alundlchnudow maurul
U dc0ad by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Sagan 25532(a)1
❑Ya ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building median,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamok us air om ucinats as dcnad by the Bay Area Air ouailty Mmagemcm all new materials for inspection.
DWI"?
❑Ya ON.
I hawmW the harardm .Lmdalsrequim nuunder Chaper6.95 ofteCalifor•
nW Health&SafetyCode,Seem=25505,25533 and 25531.1 undvawd thus if tie building
dam at cmcn ),have.Irnant os,to u my rapomibllity to mtify tic mLYpNt of tie
requirement muubemet 'micas u af.Cuune,toarOT ( Signature of Applicant Date
0
Owner or authamed agent Dau
All roof coverings to be Class"B"or better