04020036 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Co�`TRA��QRJNVPRMAT ON
n . g: -,'
BUILDING ADDRESS: PERMITNO.
CD & C INC 04020036
OWNER'S NAM - PERMITISSUEDATE
1&1E; YANG250@EtIDSANITARY /2 6OL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C7 0 t� 0
coo LICENSED CONTRACTOR'S DECLARATION
z I hereby affirm that 1 am limnacd under provisions of Chapter 9(commencing Job DESCrlpt100
< with Section 700)of Division 3 oflhe Business and Professions Code,md my license is
? y in full fo...mi.ffect.
'yqz
Umman Class Lm.x ADDITION 841 SQ. FT.'
zip Dau Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
.G^ Licensed Professional
S OWNER-BUILDER DECLARATION
Conti DN
1 hereby so affirm Nat 11. exempt Imre the Contractor's License Law for the
pO following(canon.Permit
t Tf131.5,Business and w,de io demolish,
Code:Any city ar county
which requires a permit re conswcL alter,improve,h Permit t or repair any s stone
'a
the,
he ilicausindp alto requires res the rovisinsofant forsucdre Cohpermi'toicense awpChtcmcm
as that mincing cJpursaamothe ofDivinnnfOftheB.OmeacsLicanxlaw(Cbapmr9 Sq.Ft.Floor Area Valuation
rct$ (cat he
(commencing with Section 711ndth Dosis n3 of theeged masupt Professions Code)Or
3�
that he ie exempt therefrom and the baso far Ne alleged cumpdon.Any violation of
Section 7031.5 by any applicant far a perrnittubjecu me applicant to s civil penalty of APN Number Occup ncy pe
not more man five hundred dollars($500).
❑1,as owner of the property,mmy emmende wim wages r mei(sale co .Bua0oo,
will domaw.&-..d e, heC.misnmiLicense firhoitalo fs Out
in044,Bu sine hs 35926044 . 00 Required Inspections
and Professions Codc The Condecrun License Law tins not apply lf an owner is q p
property whe yees,pdsor ed thinsuch improvements
m mantlwht dmnenbwmk himaelrm through his
oowwwo,the building
mmsuc improvement
I.vemwithin net ear of
commcipletion,
theoformic.owner-
builder
me building a improvement is held within one year of completion,me owner-
hale.). will have the burden of proving mm he did not Wild or improve for purpose of
sale.).
M1,as Owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cod.:)The Contractor's LI-
cense law dean not apply to an owner of property who Wilds a improves themon.and
who contracts for such projects with a comracter(s)licensed pursuant to the Conmactors
License Law.
�❑\I em exempt under Sec. .B&P C for this
recon
kCO P
w � WORKEf�S COMP SATIONE�SyAt1t0 ATION
I hereby affirm under penalty of perjury,one of me following decimations; -
1 have and will maintain a CerORcato of Consent in self-inure for Warkcr's Camino-
nation,as provided for by Section 37M of the labor Code,far the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensa0on Insurance,as required by Section
37M of me labor Code,for me performance of me work for which this permit is issued.
My Worker's Compensation Inumnc,cattier and Policy number are: .
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section rued not Mcomplcmd iffm permit is furore hundoeddollam(SIM)
or ImL)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers''Compenandon
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,alcor making this Cerificam of Exemption,you should
become subject to the Workers Compensation previsions of the Labor Code,you must
.JO forthwith comply with such provisions or this permit shall W deemed mvnkcd.
zCONSTRUCTION LENDING AGENCY
'rt4 Thereby affirm that mere is a mnswction lending agent,for the porfurmantt of
Ni> the work fur which this permit is issued(Sec.3097,Cie C.)
W Q Lendcr's Name
z Lender's Addmss
U 0 1 coolly that I have read this application and sure met the above infotmedun is
4L (•"' correct 1 agree to comply with all city and county ordinances and sum laws relating to
pU building construction.and hereby autharise mpreseitadws of this city to ermrupnn the
W about-mentioned property for inspection purposes.
�" gy (WO)agree to save,indemnify and keep harmless the City of Cupertino against.
liabilities.judgments,costs and CaNums which may in any way accmc against said City
U in eminerpcnce of the granting of this permit.
^t APPLICANT UNDERSTANDS AND WILL COMPLY WN-POINT Issued by:3 Date
SCOL CEREGULATIONS,—
I (_ -r-7 (' 0A ? t /0 (Z Re-roofs C7 If
(Fignaturna ulAPplicanUContmcmreD to
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at future building Occupant store or handle Int ardous mammal
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.scaden 25532(a)]
El Yen All roofs shall be inspected prior to any roofing material being installed.
TR '
Will the applicantfuture or fu-ubNo e building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
-it havardous air wonnu ems as defined by the Be,Area Air Quality Management all new materials for inspection.
District?
❑Yes [�Nn
1 have read the hara(dous materials mquircmanu under Chapur5.95 Clore Califor-
niaHealth&SamyCodc,Sections 8505.25533 and 25534.1 understand that ifine Wilding
does not currently have a Wheat,that it is my responsibility in entity the Occupant of the
requircmenu which must be met prior Or issuance Of a Ccmfcam Of Occ any.. Signature of Applicant Date
t nerorauihorixNegcm Date All roof coverings to be Class "B"or better
'—CITY OF CUPERTINO +may«)y+,� ' t*^'y�� "h /}�',`�'��f
BUILDING DIVISION' PERMIT - '%��+ONTf , kt--TO 41\lit A'T,�"'1� $
. :
BUIL DING ADDRESS: PERMIT NO.
CD & C INC 04020036
OWNER' NA - a- PERMIT ISSUE DATE
ttAySANITARY OLIO.
ARCHIIECnBNGiNEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION -- Job Description'i arcby eflne that I am licensed for er pmvirionf of Cbapwf 9(commoneing -
wiNSmdon70 )ofDivision3ofdu Busineesatnftr d nsCD&.a mylicmmis -
in full form andeffmt. - -
�z ueanm setas Lle.« ADDITION 841 SQ. FT. -
s Dam cant ECL
As CH'mail
use DECLARATION
1 understand my plain dull a used of public mrnrJs
i tad Licensed Professimul
OWNER-BUILDER DECLARATION
1 Archy.firm that I me esdmpt from the Convector's Limnu law for IM
0 o following mason(Salon 7031.5,Business and Profusions Cade:Any city or county
$f<i which mqulrcs a Permit w construct,alter,improve,demolish,or repair any uructurc
F�'an prior an its Issuance.also mqulms the applicant for such Permit to file a signed statement ggFF -
< the he isdemandpursuanttoftpmro
visiaafdnCommenc Commences Sq'.Ft.Floor Area Valuation
6$^ (mmmcadng with Section?OD0)afDivision 3 of the Business and� ProfeNnnsCoue)m t that he is memin therefrom and the buts fm ft ewnptim,Any claiNon a( non
Session 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofAPN Number Occup cy pe
not mom than rose Weekend dollars($500).
0 1,in owner of the property,army employau with waguas their sole compewden.
wlllelatheworkandthesltuchencianmthundeA anRemdforaak(See.7044,13usiness 35926044 . 00 Required Inspections
--
and Pmfnsalons Cad.-71.Cra uammY License Law dam net apply M an nwrur of q p
property woo bull ds m)mprows thereon;and woo dma ash work h imsel(or through his
own employee,provided thmaah improvememu tae nolinunded arOBcredforme lL -
hudder sthe Wilding ser improwmem Isanld within nae year or mpro a for the Owner.
' builder wIE have W Arden of proving Nn a did net Wild m improve for purpose of
talc 1.
A1,as owner of the property am conclusively contrcYng with licensed contractor to
conmrom the pmjem(Sec 7014,Stearns,and Pro(nstions Code:)The Comaboar's U.
cones law dins not apply to as owner of property who Wilde or Improvesdaimon,and,
who commentcommentfor secedectMNont
projes a cruwr(q licensed Practice to the ConvactaYLs
xv,
License Law �f
\❑ lam eaempl under Sm. � ,B&PC far this rcaann
Oar
4
_1 TZ_ f(YQ \n Date " 6( o /
�(J WORKE SCO SATION RATION rl/O
I hereby 4frnm under pculty of pedury ane of site following declamdoru;
have and will maintain a Cerdfamm of Consent to self-Imam fa Worker's Compere
salon,an provided for by Sadao 3700 of the labor Code,for the performance of the -
work for,which this porm)I is issued.
0 1 haw and will maintain Warkefs Compensation Insurance,is required by Section
3700 of the Lear Code,for the performance of the work for which this permit is Wood, -. -- -
My Workefs Compenwion Insurance curia and Policy number tae:
Cartier. Policy No.:
CERTIFICATE OF EKEMPf10N FROM WORKERS'
COMPENSATION INSURANCE
(Mb section nmd not W complemd Ifthe pennillaforone hummoddolles($100)
or kis)
1 certify that In the performance of the work for which this Permit is issued.I shall not
employ any person in any manner an in an became subject to the Workers'Compensation -
Laws of Cdifomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should -
bccome subject to the Warrior's Compensation provisions of the liar Code,you mute
.JO forthwith comply with such provWons a this permit Valla d mucked. i.
q ti CONSTRUCTION LENDING AGENCY _
F lahich thi this then lew
a connotation lending dM
ioning agency for perfermanm of
lY the wad for
which this permit is issued(Sec.7097,Civ.Cd
QLender's Nurse
zLender'sAddw
V Q I cedlfy that 1 have mud this application and eau that the aWw Information is
LU V correct.I agree 10 comply with all city and county eNinunms and sum laws mining to
O Wilding construction,and hereby auhodw reptesenudwa of this city to cnur upon tiu
Lid above-mentioned properly for inspection putpmet
�"py
(We)agree to cost,indemnify and keep may
in an site y ala of Cupertino end
City
„soy liabilitiinconses.quaram fthemsuand upOf isPCMiwhich furyin say wyamue againstsaid City
V
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AN-POINT Issued by: Date
JOUgCE RECULATIONSi
iV P_�:= c v-2 0j.-) 6. l4 Re-roofs
�mtum a�plicant,Conuacmr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant awrc ser handle harudow material
as dellned by the Cupertino Municipal Code,Chapter 9.11,and the Hcalth and Safety
Coda.Section 25532(.)'s31(.)?
❑ " ANOAllroofs shall be inspected prior to any roofing material being installed.
Y
Will the applicant or future Wilding Occupant use egmproent or devices which If a roof is installed without first obtaining an inspection,I agree to remove
rb II hnaknns air cmmormanu a dc(Incel by the Bay Ams Air Quality Management all new materials for inspection.
mics?
0Ym RTlu
I haw aced the husNon,materials mr,immemu undcrClupur 6.95 of the Califor.
nia Health&SafmyCo le,Smdmu 15505.15533 and 25534.1 understand this if the Wilding
does col curendy haw a Mount.tha It b my responsibility to badly the occupant of the
myulrcmenu which muss be met prior winuuux ala CeniRau a(Gc -�.� Q Signature of Applicant Date
ermau orimd.gent
new All roof coverings to be Class rB"or better