07100020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT , .�'''U1ri.'T1 iG`T<�R NFORMAT
PERMIT NO.
BUITg�gglpfees�:TERLING BLVD TBD — TO .BE DETERMINED 07100020
IMF R'S NAME: PERMIT ISSURDATE
HUAN—MIN CHANG — 02/21/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC tENGINEER: BUILDING PERMIT INFO
0 0
PLUMB
MECH0
woo LICENSED COMRACIOR'S DECLARATION
F 1 Mmby affirm that 1 am lisnacd under provisions of Chap¢r 9(commencing Job Description
`uf with Section 70f18)ofDivbion3 of Ne Business and Professions Codc,and my ikons is HOUSE DEMO
s � in full force and effect �"�� b
,M 4 License Clan Lm.B L'�
C
Dam Contractor
ARCHITECTS DECLARATION
I understand my plans Mall he and as public amounts
26
5 c Licensed Pnsfessi...I
OWNER-BUILDER DECLARATION
<E 1 hereby..
.tion that 1exempt from to Commences License taw for the
i p O following moon.(Section TfD 1.LS,Business and PmfWsions Code:Any city or county
which ash,saae.aim mcnnshesire.W farsudcmrnitt re a Pat,g anythtlent
prior toiu issuanco.also mquirs tW Applicant for such pennino measigned summer
❑< that W is lieenseJpurhaanitoNe Provisionmldm Crnaactor'aWcense law(Chapter Sq.F[.Floor Area Valuation
I F 9 (comms,censehtS dt Smuon 7=)the proAtimm of or due in Cimmu or'siness Li Pmfsaw(Chad)or $110 0
Nal he Is exempt thief ren and be bub for the alleged moreptimn.Any violation of
Section 7MI.5 by any applicant for a permit subjects the applicant to a civil penalty OfNumber Occupancy Type
not mom dun law hundred dollars($500). 3 7 5 2 4 0 2 6 .•V V'
❑Loi w out the pmpmty,mmy empmild.hhwagessstherwile(rob c .Bon Bonuses,will dothewoh,and the auucmmbnatinmserian Law
Out
TO N.Bnerof Required Inspections
and property
ywhobu Code:The Contractor's rd who Law doss oat apply lf an owner of q P
Own ertywho Wilda mimphawach improvements
tendo arafroforllhudh his
ownemployes,provided that wn IuIs mid it in not canoed eeredfar ale IL
halter.the Wildinggain oProvin Iahaltedidn ane year of completion.fatheowner-
builder vein have the When of proving that he did not Wild or improve for purpose Of
sale.).Ur 1.as owner of the property,am exclusively containing with licensed mnaaetoss to
jOnstruct the project(Sea 7W.Bsineu and Professiass Code)The Comracmr'e Li-
man law does not pply to an owner of property who Wilds or impales thereon.and,who Contracts for suc s projects with a cmnuamer(a)licensed puauant to We Contractor's
License L.
I.toe p oder See .B&P C fa this once
Dam
WORKERS CO ON DE RATION
I hereby Milan under Penalty of perjury one a following declmtiens:
❑I have and will main
uina Cenifisk OfConsen selftisure for WorlecesCompen-
catl.n,u provided for by Section]T00 of the V r Code,fm We performance of We
work for which W.permit is issued. .
❑1 have and will maintain Worker's Compensation Insurance,as required by SeNnn
3710.1'We Labor COM,for We perfmaxaceaf We work farwhich do.permit is issmd. '
My Worker's Compevauan Insurance camfm and Policy mumbo,am:
Carrim Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
flbb section need net he cauplened if the permit Is formic hunWed dollars($I WI
ort .)
I ComfY that in the performance of the work for which Wis Pmmit is[sued,l shall not
employ any parson in any summer so as W become subject to We Warkoss'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPUCAND If,cher making this CeniRste of Eumptian,you should
Ixmome subject to the Woher's Compensation previsions of the labor Code,you mug
QO forthwith comply with such Pmvbms or this Permit W deemed marked.
ti CONST UCTION LENDING AGENCY
[-t Ihcrebyamrm that n.cangmc Ion lending age ncT rdoperfu anceof y
ai dm wad fur which ' I s blued(Se.709 ,Civ.
a Q Lender's no
Lander.Address
U Q I certify that 1 haw mad this application and sum thu the also formation is
I8.P corms.l &me to comply with all city and county ordinances and autep ws relating to
0 building construction,and hereby amhohse reprewnmivs of this city enter upon We
fa7 above-mendaned property for inspection purposes. _
(We)agree to ave,indemnify and keep harmless the City or Cupertino against
`v,y raja liabilities,judgments,costs and expenses which may in any way ammo against aid City
U z in Co."...of Wee ng of Wb permlL
ti APPLICANT UN NDS AND WILL COMPLY W HALL PN-POINT"Issuedy: DateSOURCERE(
SignUmOTAWiAndCoh=Mr Dam
HAZARDOUS MATERIALS DISCLOSURE' Type of Roof
Will the applicant or future building occupant store mho hmandrs matorih
defined by the Cuperona Muni'pal Code,Chapter 9.12.an Hcalth and Safety
Section 15532()1 All roofs shall be inspected prior to any roofing material being installed.
❑Ys u
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.1 agree to remove
emit hairdos air Cones out in defined by the Bay Area Air Quality Management all new materials for Inspection.
District?
❑Ys Nu
Ithawmaddieligy c= flaismquimmenuunderChapmr6.95ortheCalifw-
realical"SafelyCad, nios25505,25573am175534.Iant and thhifthc Wilding t
does not current It. coast,that It b my rsposihilhY t til'y dm a mddfvdo,
requirements �h met riorlyisspahccota RG m 1 ' ` Signature of Applicant Date
Owner ormmariredagent ZV Dam All roof coverings to be Class"B"or better