05060099 CITY OF CUPERTINO WONT,
BUILDING DIVISION PERMIT WONTI2ACTOR INFORMATIs,: N
y ","�
BUILDING ADDRESS: WAYNE LIN PERMIT NDo5060099
10510 TANTAU AVE
OWNER'S NAME: FERMrf ISSUE DATE
WAYNE LIN 10510 TANTAU AVE2005
PHONE: SANITARY NO. CONTROL NO.
ARCHIECOENGINEER: BUILDING PERMIT INFO
BO EO PLUMB MECH O
riOp
LICENSED CONTBACTOWSDECLARATION JobDescription
if I bunchy affirm that 1 am licensed under provisions of Ciuplcr 9(cmtonme ng
ith Sudan 7000)of Division 3 of the Business malProfessionsCede.and my license is
n mrmuoreemdeftect. REVISION--FL JOIST IN LAUNDRY RM
is License Class Lie.is
Data Comcarter DECLARATION NO NEW PERMIT ISSUED/ORIG. #04100126
of As Asti used
DECLAc meet* '
I unticnunJ my plena Nell be uteri n public racorda
�,v Licensed Professional
c
3 OWNER-BUILDER DECLARATION
J�S I hereby mTvm that I am exempt from the Cantramars License Law for ax,
t p D f,llnwing mason.(Section 703 1.5,Business and Professiav Cade:My city ar county
$ which requires a Permit to courthouses.slim.Improve,demolish,or repair any structure
prior m its issuance.alsu requires the applicant forsuch permit to file asigned statement
Nal he u licensed purcum,mthe m
provisions plate Concosrs have Law(Chapter9 Sq.Ft.Floor Area Valuation $0
D (commencing with Section 7000)of Division 3 of NU Budnessand Professions Code)or
$ that he is exempt therefrom and the basis fee the alleged exeaptim.My violation at
Section 70313 by any applicant for a permit subjects the applkmt m a civil penalty of APN Number Occupancy Type
act mare them fin hundred dollars(f300). 37537021 . 00
❑Last ower orthe property.or my employees with wages es their sola compensation,
will da the work,and the swans is mt intended aaaerad fovak(See.70aa,Bur pass
and Parenlons Cade:The Conuamors License Law don oat apply a m,wner of Required Inspections
property who Wilda or Improv the reen.and who does such work himael f or t aaugh his
awn employees,provided thaLSueh Improvements art not Intended moBead formic.if,
haveveq Ne building or improvement is cold within oro)em of completion,Ne owner.
Wilder will lave the burden of proving that he did not build or Improve fee Purpose of ['
ale.).
❑I,as owner of the property.em exclusively contracting with licensed contractors b �r
construct the Projem(Sec.7044.Business and Profession Cade:)The Cmleacers U. V /
man taw does but apply ro an owner ofproperty'who Wilds or improv thercon,and, ^ Q
who convects for such projects with a eontrmror(s)licensed pursuant in rue Contractor's
License1m taw. �I
1 Law. under Sec. B h P C ar this
.��''' WORKERS
(D 2 V
1 WORKPRS COMPENSATION OECIdRAT10N
1 hereby atom under penalty of perjury one of the following declaration:
❑I haveand will maintain•CeNOeste of Consent eselfdnsue fm Workera Compeo- ,
cation,as provided for by Section 3700 of the Labor Code,for she performance of ate
wort for which this permit is issued.
❑1 ban and will maintain Workers Compensation Insurance,as required by Section -
3700 of the labor Cade,for the performance of the wank for which this permit is issued.
My Workceg Compensation Insurance carries and Policy number sue:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seance need but he campleed if rue permit Isfmane hundred dollen(SIM)
or less.)
I artily that in the PMormanm of the weir loo; this permit u issued,l Nall rot
employ any person in any mmner�oul barCo�e�sydectmamwohen'Campenseam
Lam of Calific ia,Dare g 1 awl 1
ApPlicw
NOnCE TO APPLICANT. 'a cr king this Certificate of Exemption,you should
become Subject to the Warkv a CJmpcwdes provisions of ate LaMar Cade you mot
,J 0 forthwith comply with such provision or this permit Nall W domed mated.
z 0 CONSTRUCTION LENDING AGENCY
F N 1hercbyaBirre thss tiara Ha conmactim lending.genry far ate perfarmanaof
IL' IM work for which this permit Is issued(Sec.309E Civ.C.)
tg1 Q Landers Name
]z Lenders Addmm
U O I ceNty that 1 have read ads applicmlm and able arm rite above udormNm I. ,
IL aspect I agree in comply with all city and county bNinmm and mate laws mlating as
p building conwuetian.and hereby authorise represenmiv of this city in mor upon lM
{i7 Alava-mentioned property for inspection purpmea
(We)agree to save,indemnify had kap harmless rue City of Cupertino against
,..a rrAA liabilities,judgments.eats and expenses which may In any my accrue against said City
UZ in consequence of the gnning of this permit.
cow APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOW INT Issued by: Date
SOURCE REGULATIONS. �71 �
Re-roofs
Sigmve ofApplicautContraeflor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant lir future building occupent sloe orhandie hoaNars material
as dented by the Criterion,Municipal Code,Chaper 9.12.and the Health and Safety
Cola.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
[3y. XiNo
Will the applicant or future Wilding occupant use equipment'ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haraNnus air mnumiunu as defined by the Bay Arca Air Quality Mmagcmcm all new materials for inspection.
District?
❑Ycs Ru
I hevc and the hasaNsmsmauMale myuitemcnts undcrClupter G93 plate Califor-
nieHc.W&Safety Cotle,Secu,ns25305,25533md25334.1undcrnandthmlfue building
dao ter currently he.a tenmL Not it is my responsibility in entry faceuuuqqqmmmloran
m
myulmmenu which roue met priormiasuce of a CcNrv:ae of,Oc9uPan a Signature of Applicant Date
Owner or authod�ag (6a. IF��L417ae I All roof coverings to be Class"B"or better