04040021 CITY OF CUPERTINO '' 1,7 ` '` " '
BUILDING DIVISION PERMIT !� NR� T ,m„F`„p��' ;' ,
BUILDING ADDRESS: PERMIT N0.
BAY BUILDERS 04040021
wNER'S NAME: PERMIT ISSUE DATE
SAM WANG
NE: SANITARY 4.4 OL NO.
ARCHITECT/ENGINEER' BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X100 LICENSED CONTRACTOR'S DECLARATION Job Description
8 1 M y affirm Nel 1 am lieco pAder prevision of Chapter 9(commencing p
wIN Sm O(p)o(Divi¢ion30f thcU aMPmfessions CSM dory Dcameta
flmmnf .rodercmg Lk.R REVISION--TRUSS/ROOF
Z� Dam Class
Dam Contractor
dcARCCI'S 266 ON NO NEW PERMIT ISSUED/ORIG. ##03020093
I
1 unrsun y plan a Pu records
6
3 C Lkcnsed Prodossiohl
0min from
DECLARATION
1 herchy affirmN t I am exempt from Ne Commcmh License Law for the
p O fallowing mason. emit t T ons m Business and vs,de io demolish.
Calc:Any can or county
m m which requires a permit to ecnmmct.alma improve,h Permit t ri repair ed structure
FZQpoor it)its iensedpalsorequires theapplicantf Con Permitsoicessignedsummcm
NOIhelncing ithSccanlmNepmvi¢IOMafNCConusiness1JMnY1JW(Chapmf9 Sq.Ft.Floor Area Valuation $0
load We sempthsection 0DlB of and the
n 3or oft he Business pt Pretensions Code)of
tins he is exempt therefrom and Ne bun for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit mbjecn the applicant o a civil porosity of APN Number Occupancy Type
act mom than five hundred dollen(5500).
❑I,.ownerafthepmpeny.mmyemplayceswiNwagu"thelraole=pepatlon, 375508018 . 00
will do Ihework.and theswnum is not intended oroRemd rorsele(Sec.1D44,Businea
and Piefessians Cod.:The Communes License Law does not apply M an owner of Required Inspections
property who buildsorimproves Neuron,and whoduessuch work himself or through his
now employees,provided that such improvements are not intended mortared for tile.if,
however,the building or improvement Is sold within one year of completion,Ne owner-
bullder will bave the burden of proving Nat M did not build or improve for purpose of
Age.).
❑1,as Owner of the property,am exclusively contracting with licensed commons m s
construct die project(Sec.7044,Business and Professions Code:)The C.ntractnes U.
rose Law docs not apply in an owner of properly who builds at improves Thereon,and
who contracts for such pmjecM with a conlon mr(s)licensed pursuant o the Contractor's
License Law.
Pel'mmcrhpturomr See ,B&PCforthismmm
mer Date
WORKER'S COMPENSATION DECLARATION
1 herchy of fr n under penalty of perjury one of the following declarations:
❑I have and will maintain•Cer ificamof Consenlm self-inmm forWorem's Compen-
sation,As provided for by Section 37M of the labor Code.for Ne performance of Ne
work for which this permit is issued.
❑1 have and will maintain Worket's Compensation Insumnco,as required by Section
3700 of Ne Labor Cede,for the performance of Ne work for which this permit is Issued.
My Work�err—s compensation Insurance artier rod Poliry�ns9u,ml�bn�er a�m:
CERTIFICATE OB3GE PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notbecompleled ifthe ranch 1,fmonc hundreddollars($100)
or less.)
1 earthly that in the PeRnrmance Of the work for which this Permit At!good,I shot not
employ any person in ym nes o ome subject the Worker!Compensation
Lawa of Califmnh au -9P_'I's"
ApPlicam �Q
NOTICE TOAP :IL after making this Certificate of Exemption,you should
become suhj
A=
Worker's Compensation previsions of the Labor Code,you mum
.J,'Z. forthwith comply with such provisions 0r this Permit shell be deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-i I hereby gBrm that Nem is a comuuminn lending agency for Nc performance of
ai r� the work for which this permit is issued(Sec.3091.Civ.C.)
W�A Lender'a Nam.
z LcndWs Address
U Q 1 endify her I have read Nis application and sum Net the about information I. '
Ifr f" correct.I agree t.0 comply with all city and county ordinances and sate lases relating to
O t.7 building c.nswetim.and homey mNorim represenmtives of this city to enter upon the
L1a ahow,mentioned property for inspection purposes.
(we)agree in save,indemnify and keep harmless the City Of Cupertino against
ccn liabilities,judgments.costs and expenses which may In any way accom against mid City
V 7 in consequence Of the greeting of this Permit.
r7 APPLICANT URSTANDS AND W'tT- �Y WITH ALL NON-POINT Issued by: Dale
SOURCE REG TIONS
\ _nuur ��� Re-roofs
Signa O(A HAZARDOUS MATERIADISCLOSURE Dam
HAZLS Type of Roof
Will the applicant or future building Occupant store or handle hmmdaus material
as d.Racd by the Cupe m,Menic'Pal Code.Chapter 9.12.and Ne Health and Safety
ode, sedan
❑Yate Y.25532(.)? _�J/ - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit W.Ohm s it comment nu cloned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have mad Ne hmardous materials requirements under Chapter 6.95 of the Calirm-
meHealth&Sit eiyCodc,Sections 25505,25533 and 25534.1 understand that if the building
does not cu ly have a eneet that it is my rospmsibilily,in nodfy Ne Occupant or be
.,.I re whichmulbemetprolacenuanecore eafmamuf u cy Signature of Applicant Date
o n... sem Date All roof coverings to be Class"B"or better