05120109apesC
�ZW
o�
nr�
JyU
e
10
y
�OC
L`t
'Y
_z>
EFC
z
z°
d A
5z
U
OF
U
Fa
�z
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
IVONTRACTORINFORMATION k
BUILDING ADDRESS:
OLIVIA JANG
PERMIT NO.05120109
19078 STEVENS CRK BLVD
R'S NAME:
PERMIT ISSUE DATE
OLIVIA JANG
19078 STEVENS CRK BLVD
01/19/2006
NE:
SANITARY NO, CONTROL NO.
ARCHITECTtENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
= 0 0
LICENSED CONTRACTOR'S DECLARATION
Y
Job Description
I hereby affirm Thal 1 am Incanted under previsions of Chapter 9 (commencing
p
with Section 7") of Division 3.f be Business and PmfCSSbms Codc, and my lice.. is
in fall Co., sad effect.
RELOCATE GAS METER /REPIPE GAS LINE
License Class Lie. p
Date Contractor
ARCHITECT'S DECLARATION
#05110142 VOIDED APPLIED BAL OF REFUND 23.34 TO
1 understand my plans shall W used as public records
Limed Professional
OWNER-BUILDER DECLARATION
I Wrehy affirm that 1 em exempt from the co "Clan's License Law for the
following mason. (Section 731.5, Business and Pmfcaiuns Code: Any city or county
which requires a permit to Construct, alter. Improve, deprol h, or mpalr my Structure
prior m its issuance, also requires the applicant for such permit to file a signed statement
that he is limaxed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area Valuation
termmencing with Section 7") of Division 3 of be Business and Prt imiom Code) or
$1000
Nat W b exempt thetefrem exemption. end the basis for the alleged emption. Any violati on of
Section 7031.5 by Any applicant for a permit subjects the applicant o a civil penalty of
APN Number
Occupancy T
P )' yPe
not more Nan five hundred dollars (5500).
0 I, u owner of the property, or my employees with wages u their Cole compensation,
will do be woh, and the structure is not immndcd of offered for sale (Sec. 7064, Business
and Pmfmakand Cork; The Contractors Licetae taw does not Apply to an owner of
Required Inspections
property who buildsor imprmes thereon, and who doessuch work himself orthmugh his
own employers, provided Thal such improvements arc not intended m offered fertile. IL
however the building or impmvemenl is said within one Bear of complcuon. the owner.
builder will have the burden of praying that he did not build or improve oar purpose of
ate.).
0 1, as owner of the pmpeny, am exclusively contracting with licensed Contractors in
construct the pmjca (Sec. 7044, Business and professions Code:) The Contractor's Li
mruc Law does ooh apply to in owner of property who Wilds or improves thereon. and
who contracts for such projects with a commelor(s) licensed pursuant to the Contractor
Lear. Law.
O l am exempt ann&,SSex% ,B& P C for this reason
s// 0 6
WORK 3COMPWSA ON DECLARATION
1 hereby N1rm under pevlly of perjury one of rue following declaretiens:
1 hi ve and will maintain a Cenifinte of Contend to self -insure for WorkersCompen-
atian, a provided for by Scedon 3700 of rte labor Cade. for the performance of the
work for which This permit is issued.
0 1 have and will maintain Workers Compensation Inw .. ss required by Section
3700 of be labor Code. for the performance of the work for which this permit is issued.
My Worker's Compemation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mats section need not W completed if the permit is for. hundred dollars (SIM)
of less.)
I certify thin in the performance of the work for which this permit is issued. I shall nut
employ., pawn in any..Mo . as m bemmc subject to the Wonlaus Compensation
Laws of California. Dale
Applicant — q
NOTICE TO APPLICANT: If, of mg this Cenificete of Exemption, you should
become subject to the Worker's Compensation previsions of the IsWr Coda. you mail
forthwith ComP1Y with such provident or this permit shall W tamed .Cooked.
CONSTRUCTION LENDING AGENCY
1 hereby alrum that them is a construction lending agency I'or the performance of
the work for which this permit is issued (See. 3097. Civ. C.)
Lent" "A Neme
Lender's Address
1 certify Nat I have head this application and state that the mve information is
correct. I agree m comply with all city and county ordinances and slate laws echoing to
building eonstroclion, and hereby audtarim representatives of this city to corer upon the
abavibet,judgments. id pmpc for
penes purposes.
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
a
tit
crab and expenses which may in any way ¢auc again. aid City
in consequence nce of the this Pe
A APPLICANT of UNDERSTANDS this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
/ _� ��
Issued by: Date G
I // 9 �' 6
Re -roofs
Signature of ApplicanVCOmrator Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding occupant tram or handle husrdous material
darned by the Cupertino Municipal Code. CWpar 9.13. and the Health and Safety
. Section 25532(47
❑Yet ON.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future Wilding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
it hazardous air contaminants ss tefrncd by the Bay Area Air Quality Management
all new materials for inspection.
District'
OYCS ONu
1 have real the hambindsmaterialsrequi.ments under Clulpter6.95of the Califor-
nia Hca W & SafnyCede, Sections 25505.25533 and 25534.1 understand thotif the Wilding
dots not currently have a tenant Nat it is my mspmtsibility to notify be eaupam of the
requimments which must W At prior to issuance of A Cenlgcaw of Occu AMY
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owncrorauthomcd agent ' Dale