01080025 CITY OF CUPERTINO
BUILDING DIVISION p- IT CONTRACTOR INFO ^4ATION:
BUILDING ADDRESS: IW
PERMIT NO.
10599 N STELLING LIN-HAI NAN & HSIAO-YUN AN01080025
OWNER'S NAME: APPLICATION SUB DATE
LIN-HAI NAN & HSIAO-YUN TAN 10599 N STELLING 08/07/2001
PHONE: SANITARY NO. CONTROL NO.
C rc z ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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z m z L.they II cCONTRACTOR'S DECLARATION Job Description
1 hcmby affirm that 1 am licensed under provisions of Cs Code,and
(Commencing
�w F-1 is inSmiore andefect. on3of the Businessand Pmfessiunx Cale,antl mylicensc DEMO.
KY ke is infullforce and effect.
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c' a.O Dam Carameror
3 a.y ARCHITECr'S DECLARATION
O 4 1 understand my plate xhall he used as public records
Ipso
ar do Licensed Professional
I a OWNER-BUILDER DECLARATION
1 hereby infirm that 1 am exempt from the Contractor's License Law for the
1-z a following reason(Section 703 L5.Business and Professiuns CCda Any city or county' $BOO O
E E o which requires a permit[it am
nmct,alastructurer,improve,demolish.or repair any structure
wiauee
prior to its en .also requires the applicant for such permit to rile a signed statement -- - -
a. that heislicensed pursdaoltuthe previsions of the Contractor'.License Law(Chapter 4) pySsGk�s.ypE,[ }❑���lOOigAAy.��ea Valuation
(commencing with Sen son 70001 of Division 3 of the Business and Profewi.ns Cade) 32-MOTT,
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
-ofSection 70315 by any applicars for a permit.whjects the applicant to a civil penalty saApp �.7
of not mum tban rive hundred Collars(5500)' NO AS IUq�ED INSPECT ONS Occupancy Type
❑I,as owner of the property,or my employees with wages as their sole compensation.
will do the work,addthesvuaure is may intended or offered for sale(Sec 7044. -
Business and Professions Code.The Commetor s License Law does not apply to an Required Inspections
owner of property Who builds or improves tomem,and who does such work Novell
or
.
c through employees,prthat M1improvementst intended or
Come
le f ..,I Il h th hu W e pro m t Id thin no
Completion,thebu ldc 11 ha N burden orp gthath did t b 'IJ or
improve for limptoo of sort.).
ash - to Business
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ravine
n.t t th p ) t(S ]Ru B d profession,Cod �1 ThCnnuanm s i
License IW d et ecl tPrnlss f mememobuld p sIhtom
Ci h contracts for apply p contracmns),I d p am t9 the _ -... .._... .".. ..
t th P Pen Y
Cont t f. L
❑I a a empt B&P C f nim'maun `
ate 2
_vkORKER'S COMPENSATION DECLARATICHI
-- • I hereby aRmr under penalty of perjury one of the following declarations:
❑ 1 have and will your. In a Cce fieme of Comm to self-iro re for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
performance of the work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as maymnal by Section
37M of the Labor Cede,for the performance of the work for which this permit Is
issued-My Workers Compensation Insurance currier and Policy number are:
carrier:.. A e (11t 7 Policy Na: .. ..\. _.-. tats.._ .... s':
CERTIFICATION OF EXEMPTION FROM WORKERS' t-
COMPENSATIONINSURANCE '
(This Seaton need not be completed if the permit is for one hundred dollars
151001 or Icss.) -
1-certify thefin the Isafomunce of the work for which this permit is Issued.1
shallnot employ:any person in any manner 1.u6 1.become subject to he Workers
ppli
Applicant
Low,of California. m
Da
Acant n
:NOliTCE TO APPLICANT:[L after making this Ccrtifcam of Exemption.you should,
become subjecto the Workers Compensation provisions of the Inbar Code.you used
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forthwith comply with such provisions or this permit shall be deemed revoked.
F.Z) k CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a c.nstmetion lending agency for the perfonname
,.. of the work for which this permit is ismed(Sec.304].Civ.C.) . ..
y 17 Lender's Name' . . . .,
_,Z Lendrr's AMms, _ 1
v'Q 1«rlfy that I Lava mad thio nppbcntiat and emte the d s abme information is
correct.1 agree to comply with all city and county ordinances and state laws mlming
C.0 to building construction.and hereby comerim repr2senutives ofthis atym enter ulron
Fy the move mamboed property for inspection purposes.
IY (We)ogreemwre.indemnify and keep harndess the City of Cupeein.against
W liabilities,judgment,,cuss andcape se s wh ch miry In any way acme against said
U Z. City in'conscyuence of the granting @is permit.
APPLICA, 1NDE STA\OS Ai-1WILLCO>1PLY WITHALL NDN-PDIhT Issuedb Date 7
. .NLA DNS. —6 y'
,tare of p tarVC... n.. .Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
.
Will the aplikkanta future bodd'mgoecapartsure ofhandle"absusmatenal ..Type ofRoof.. .. ._ . . _ _. .- ._.. .
as defined by the Cupertino Municipal Curie,Chapter 9,12,and the Health and Safety. _ ,
Code,Section 2553200'. I t
oyes tiry. - All,roofs shall be inspected prior to.any.roofing material being installed.
` Willthe applicantorl.lumbuilding iseepentuse equipment ordeviceswhich If a root is installed without first obtaining an inspection, ) agree to remove
emir haaaidous air contaminants as di fned by the Bay Area Air Quality Management
Di.trim all new materials for inspection., Applicant understands and will comply with
DYer 0 N all non-point source regulations. ,
1 have read the huzWuus materials requirements under Chapter 6.95 of the
California Health Be Safety Code.Sections25505,25533 and 15534,1 understand that
if the building does not currently M1ave ant ohm it is me responsibility to notify the
u m of the require ems which strobe met prior m issuance of a Cenifeme of
pane' 2 _ Signature of Applicant Date
-
net
,auto.lied
agent
Dam B All roof coverings to be Class"B" or better
OFFICE