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CITY OF CUPERTINO
0
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION
BUILDING ADDRESS:
T 9O6P STP.VF.NS CRK RT.VT)
MSI ENGINEERING & IMPROVE
ENT8'005120120
"ER'S NAME:
PERMIT ISSUE DATE
OLIVIA CHANG
1509 TERMINAL AVE
01/12/2006
NE:
SANITARY NO. CONTROL NO.
(408)399 -9733
ARCHITECT /ENGINEER:
BUILDING PERM R INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Met, affirm Nn 1 w licensed urukr provisions of Chapter 9 (commencing
with Section)0()(17 of Division 3.f ft Business and Profcui..n Code. end mylicense is
in full fume and eReet G
EWER LATERAL & ON -SITE SEWER (133')
Daery aW Lie..
Dam 11.14LtJV Comncmr
5' LATERAL CONN.
ARCHME S DKC RAT ION Y of q l tI
1 understand my plans shall bo used u public records JJ
Licensed Pmf.uianaI
OWNER—BUILDER DECLARATION
I hereby .I'firm Thal 1 am exempt from the COnuactOYS Uct.. Law for IM
fallowing mason. (Section 7(5 1.5. Business and Poef,,sians Cade: Any city of county
which requires a permit to construct. after, improve• demolish, or repoir any structure
prior to its insuaMC, also mgalres the applicant for such permit to file a signed statement
NatheislicenwdpursuanttothepmvisionsofthcCon vector'sLkensolaw(Chapmr9
Sq. Ft. Floor Area Valuati 18600
(commencing with Section)OOO) o(Division J Ofde Business and Professions Crde)m
Net he u exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for. perms subjecu the applicant to a civil penalty of
not morz Nan Gw hundred dollars ($50B.
APN Number
O
Occupancy Type
37507045.00
0 1, a owner of the property, tar my employees with wages as Man sole compenution,
will do the work, and thc swmure is our intended or offered for sal. (Sec. 7614, Boon.
and Profetions Cade: The Convectors License law does trot apply to an owner of
Required Inspections 1 y
property who builds orimprnws lhercon. and who doeeeuchwork himself orthrough his
own employee• provided that such improvements are not intended oro0ared (ornate If.
however, Me building or improvement is sold within one of completion, the owner.
year
builder will nave the burden of proving Nat M did not build or improve for purpose of
sale.).
❑ 1, as Owner of the property, am exclusively contracting with licensed convectors to
construct the project (Sec. 1044, Business and Proforumm Cade:) The Contractor's U.
/
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cruse law doses not apply to an owner of property who Wilds or improve thereon, and
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who contracts for such prejecs with a convacmr(s) licensed pursuant to the Convactoes
71
License Law.
E) [am exempt under Sec. , B k P C for this mason
(A
Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declort ore:
1 haw and will maintain a Certificate of Consent ulNneum for WorkcesCompcn-
"Moo , u provided for by Section JT00 of the Labor Code, for M e performance of the
work for which this permit is issued.
❑ 1 have and will maintain Wmkces Compensation lnsurznce, u required by Section
", of Me labor Code. for Me performance of the work for which this permit is issued.
My workCeet —Campe`w,�ton, Nsunnce amiss and Policy num�kran, �C'
Carrier. J,� 't Vl'f N PoIiry NO.:I�^WU —�L1 —%
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tots see(iMt need not W completed if MM permit is for One hundred cinllars (g Idn)
of lest.)
1 certify that in Me performance of Me work for which this Permit is issued. I snail not
employ any person in any manocrsn as to become subject to the WOrkcor Compensadon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: It. after making this Certificate of Exemption, you should
become aubjen to Me Workers Compensation previsions of Me Labor Code. yen must
forthwith comply with such provisions or Nis permit shall W deemed revoked.
CONMUCDON LENDING AGENCY
I hereby aRrte that Herz is a comuuctinn kheing agency for he poor .onso. of
Me wmk for which this permit is issued (Sec. 3M, Ci, C.)
Landers Name
Undcrs Address
1 certify that I have red this application and suss that the show information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
Wilding construction, and hereby auNOrim represenutims of this city to enter open Me
above-mentioned preperty for itspcedrm purycasts.
(We) .gree to sane, indemnify and keep hapless the City of Cupertino against
liabilithi judgments, toss and expeucs which may in any way accrue against said City
in consequence of the Starting of this peon.
APPLICANT UNDERSTA DS AND WILL COMPLX_VAITH ALL NON -POINT
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Issued by: Date
RCEREGULATIO
•Re-roofs
U W
ram fA IicanVCOntractor
Derc
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Me applicant or (more building occupant atone or handle harardms material
u defined by the Cupertino Municipal Code, Chapter 9.12• and the Health ad Safety
'e, Section 25552(a)? —/
Vas T
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Or future building Occupant use a or devices
PP g p
If a roof is installed without first obtaining n inspection, I agree to remove
g
I, hasardnus air conuminans u do d by de Bay Area Air Quality Management
a Air a when
uicM?
all new materials for inspection.
❑Yes u
1 havereadthehvardous materialsmquiremansunder Cnapmd6 Calding
niaF SafctyCod., Scctianshat alfMhe
Wilding
mu, it IS Y NMih54.1 WMadlnMnmifdte
Dues rot currzntiy M1aw a tenant that II is my vpouihility to ratify the oecupanM of Nc
men wen p iss.aoee acenihcaateo aapanry.
t (Z
Signature of Applicant Date
All roof coverings to be Class 'B" or better
weer ar allori.ed anent Date