05050064 I,'
CITY OF.CUPERTINO - >�• nwrarxea.-qtr i"f&^> .3 t .�ap'" ''
suiLDmc Drv!SION' PERMIT. CONTRACTOR INFORMAI*ION :
. , - sn't &ts x.M7a i<
BUILDING ADDRESS; PERMIT NO.O 5 O 50064
OWNER'SNAME;' '"'f tl PERMITISSUEDATE
RYAN & LOUISE SIU
' JE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER; 1 BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
moo ,i ' LICENSED CONTRACTOR'S DECLARATION Job Description
I hemDy affirm"IS are limnsed under provisionsof Chapmr 9(mmmencing p
with Seethes 70110)of DhJuon 3of the Business and Profcsdons Cade,and my license is
r hNpfoeaaod'erceer'1 ':. Y , REMODEL-KITCHEN/LIVING� UDIO
�gZ Wcense Clain^- c " ' - Lk.g
D01e f'•7'•cfr CenliYmr r-
S'+. my
DECLARATION �®
1 wdersurid my plena shall tic umd u public records ,J
1 aD M Licensed Professional
OWNER-BUILDER DECLARATION
hereby' "m Nal 1 am ucmpt Imm Na Comone"a's Lkcnu Law far the 90p�
p o following moron.(Smtivo To"' Business and Professions Code:Any city"'num"
which equirns a,permil m en.lroct,alma.W prove,demolish,ter spur any a—'.-
we
wctue $40600
} uadW Its luvance,also mgtu me applicant fo.Co., "ohm Bleasig.J xtaumenl
Naloe is lI--dpursunt-Me Provisions of Ne Conlncon. Llmnse law(Chapler9 Sq.Ft.Floor Area Valuation i
i (eommcnctng wish Section 7000)nf Divtsion 3e(thC Business ntl Profusions Cnde)m
Q Nal he b comp,meerrom sed the buts far me alleged esemption.Any Arduth t of
=-7031.5 fiby any applicant far a permit objects the applicant m a civil penalty of
omen AM ser pansy Type
not. ve handuddelhn(M), I
❑I,u owner oRW propatY.ter mY emplaycu with wgns u Meirrolc compe...Ron, '
will do Ne wurk.and Nemactuie h.1 InerbederoQered forule(Sec. Bonuses
and Profession.Cade:The Centrumes License Lew does cat apply in an ow.r or Required Inspections
properly who builds orimp.va thernn,and whoda ouch work himselforThrough hit
own employees,provided Mut such improvements arc not Inunded..ffend tarsale.If.
however.Ne building or improvement is mid within one year of completion,the owner- '
builder will have the burden'of proving Mut M did not Wild or Improve for purpose of '
oto
is owner of We pro-prey,am exclusively contracting with licensed contractors to ,
construct the project(See.7044.Business and Professions Code:)The Commaces Li.
ceiud law dean not apply to an awtur of propeity who Wilds a,unproven thereon.and,
who contracts for such projects with a canuumr(s)limmud pursuant to the Contractor's
License law. -
Olame. u 'See BA,PC ar ml axon
e Data
OMPENSATIONDECIARATION I . .-` „_:,.�—"—� r .•..'.''•.- :
I herby affirm be her
peuhy of perjury am of the following declan,ians: ,
❑Ihsmandwille naCaWficamo(Conuinmu161in.ef.r WortrBCompcn.
nil..as provided far by Seedan 3700 of Mie labor Code,for the peAomtutt of the -
workfor which this permit hissued. - i
❑I have and will maintain Wormes Compensation Insurance,as required by Section
3700 of Ne latmr Cade,forme performance of the work for which this permit is issued.
My Workers Compensation Issuance carrier and Palley number art:
Cartier Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This section need not W canpleed If IW penult 4 foram:hundred dollen(11100)
or less.)
1 certify Not in the performance of the work for which hla peanit he lamed,l Nell not
employ any person In any manner an as to a Worker'Compensation
Law'oICalif tee
Applicant
NOTICE TO AP . f er k n i Ceniffca,of Exemption.you should
Wcome eubjmt m :K rker's Compensation provisions of the tabor Code,you must
.J O r mwithcamply 'm ch provide.or this Push hall be dmmed revaked.
z► CONSTRUCTION LENDING AGENCY -
j-r l beebY affirm that Mere is a construction lending agency for the performance of ,
Dl, the work far which this permit isissued(Sec.3097.Civ,C.)
CLW Q Lendses Name
.7. z Lender's Add.
U O - 1 mNTy that 1 have mad this application and s e text Me above Information is
{i, r'! caned I agroe to comply with all city and county oNiwun and sure laws elating in
C) rV' building construction.and hereby aumod>e representatives of this city in enter upon Me
W aleve-mentioned property,far Inspection pmtiweu t
1 (We)ague to save.Indemnify and kmp harmless the City of Cupertino against
,.yy Imbilidesjudgmenu,cous and expense,which may in any w'ayacerue against mid City
U7 Inca mmce of Uug Mn armb permlL
r7 APP a' an SAND WILL COMPLY WITH A L NO POINT Issued by: Date '
SO R GULA ��
Re-roofs
Signuu e f pliunVComric' Dim
HAZAROf US MATERIALS DISCLOSURE "Type Of ROOF
I applicant or future building occupant xtme orhandle hazardous material
u @fined We CupeNno M pal Cade,Chapter 9.13,sad Me Health and Safely
sae.s3 ea:ss32(a)7 All roofs shall be inspected prior to any roofing material being installed.
�Yan Nu
Will
thc."'man car mmm banding a mp.nt m c eyaipmem car kyfas which )If a roof is installed without first obtaining an,inspection,I agree to remove
emir hoia neon ur cntaminenu defined by Me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have mad the huerdmis materials reformation under Chafer 6.95 of the Califon
nh Kut &Suety Code Scninw 25505.25533 amt 25534.I mul reend mu if Me Wilding
d amenity h 4 that it h my responsibility to ratify the .1 of the
all auwhi user Poor toiuunmanCeroreateof Kiyy v� Signature of Applicant Date
G/
Owns a merimd ape. All roof coverings to be Class"B"or better
Da