02030033 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INTORMATION:
BUILDING ADDRESS: PERMIT NO.
10798 WILLOWBROOK WY 02030033
OWNER'S NAME: APPLICATION SUB DATE
CHANG JENQ-SIAN AND SUH-SHI G 03/08/2002
pS HIONE: SANITARY NO. CONTROL NO.
W O O ARCHITECTIENGINEER: BUILDING PERMIT INFO
E BLDG ELECT PLUMB MECH
�i I I CJ L.A I I
LICENSED CONTRACTOR'S DCCLARATION
Z in 1 hcrcby aRrm Not 1 am licenud under provisions of Chapter 9(commencing Job Description
'En t:qy with Section ")ofNW..3oldie Ba,,.apjhd P-•ro�fessions Cod,,md my license EX
PGE OUT.
iegI 3< Lcanrc s. vnd s 0 U, ' /'OckiL, a Com r C(ILt Barn ARCHITECT'5 DEC T N2 O 1 understand my plans shall be used as public retards
i L6 a.O Licensed Professional '
OWNER-BUILDER DECLARATION
m I hereby affirm that 1 am exempt from the Contractor'&License Low for the u
L?< following reason.(Section 7031.5,Business and Professions Cade:Any city orc.umy
— P rtoitsixa t swnt,sher,pplisma from,demonist fie a sir enynmcmre -_- - .-„_--- - ___ - _
or Nei he @ exemtt.1 Iso dreg.res Neapplicam fm such permit m filar sigrcd sarcmmnb --- --
D whmh requires a permit m con
po
(commencing wit pursoi he pro Divisinions tof he the Bmsmrs Li ad P.fLaw
.rs Cuda)
$q, p[� 1p pr .., ;yw Valuation
with a)d the basisothealdjeciesuni Professions Code) � ( }'a'M,d�36721j�4�/'�
p y applicant
the basis for the alleged neicant t.Any l Paean -
-of Section 7031.5 by any applicant for v permit subjects applicant too civil Penalty {p,ks +}����y�r/,,�,yk,}y���
of not more than five hundred dollars(S500). 301PN iC H PLUMBI !'`"�c' "' Occupancy Type
°1,as owner of the property,or my employees with wages as their sole compensation,
-will do the work;and the stmcture-is"not intended or offeredfor ale(Sec:T04I4;
Busirins and professions Cade:The Contractor's License law does not apply m an 304 - ROUGH EhMq- iJMVtions'' (' '-
a
owner of property Who builds or improves thereon,and who docs such work himself
_or Nraagn his own employees.provided that such improvements am not intended or. __.... _5 0.5_..—... F.I NAL. ELECTRLCAL......._- ..__.
offered for sale.If ho a er the building improvement, sold iinhm one year of -
completion, ow
on,thene brWllhavet
uldih Mrd fprovnotWldor
ingthathedidi507 — FINAL PLUMBING
improveforpapaseofeal..). 508 - FINAL MECHANICAL _
co I,as owner of the progeny, Business
contractingfe with licensed commnors's .' < t t
iceWm the project(Sec.]Doan Business and Professions Code:)The Contractor's
License law docs not apply to an owner th progeny who builds or improves,. .6.
_and.wctors Licensfor.surh.projttm viN.a.contrvemrls)IittnsW.purwam m.NeContractors am eats pt unse Law.
❑1 em exempt under Sic. -' ,B'&P C fonhjs reason .it i[•.,: rr�'t�4
Owner .. .'Gate
WORKER'S COMPENSATION DECLARATION
1 hereby a1Brm under penalty of perjury one ofdhe following declarations:-
° 1 have'and will maintain a CediGcaac a(Conran in wtf-insum for Worker's
Compensation, as,provided for by Section 37W of the Lehr Cods, for the
performance of the work for which this permit is ismcd.
°I have and will domaimin.Worknt Compensation Insurance,u acquired by Section
3700 of the labor Code,for the performance of the work for which this Nrini(is
n
,
y rkces C mpcnsaoon Insureram career and Policy number are:
I .-
ner �C M) Uj' �'^P''Policy No'sr!1J t�X' �`",7p /� J s - ;.. -. .. ...... .. ... .c: l -..
ERTIFICACOMPENETIONFMKIINSURANCE.-
(This
). S ] .'.
_ �•,�, -
COMPENSATION INSURANCE
(This section need not be complcmd if the permit is for one hundred dollars t "'t t
(S100)-Hass.)
' I comfy that in the performance'of Ne work for Which N perms s sued I
,hall not employ any Person in any mummer so as to become subject to the Workers "
Compensation Laws of C.Ificianum Data
-APPlidam.
NOTICE TO ct to beA T.Workers
fmr making Nisovisio sof of Exemption.yoou mind
0 bcee i63enmthe,suchpComps.or,ton provisionsofd Leber CWC reidse . s
forth M comply iN such prov,xions or this carred shall bo deemed revoked.
"CONSTRUCTION LENDING AGENCY
1 hemby aRrm that them is o consmucao le dt g egam,y for the performance
of Ne Work fdrwhich his perenitis issued
sia,309] Civ.C)
Under's Numc . .. r . , .,...,-. , .__ _....-.._ .. .. .... - _.._.. ..
Lender's Address' ^'
t..1--0 I cenify that I have reed this application and nate that the above information is
W coma.1 agree to comply with all city and county ordinances and state laws reining
to building consnvhtion,and hereby authori u mpmsenmtives of this city to enter upon
-kI the above-mentioned property for inspection purposes. -
(We)time m save;indemnify enify and')fee,h knits,the City of Cupcnino against
Fn Vi liabilities,judgments,costs and expenses which may in any way accme against said
t.1 City in consequence of the granting of Nls permit.' ' '._;
APPLICANT UNDERSTANDS AND WILEC pbYWTTH ALI:LNON-POINT " Issued { w
sou cE BEd ILATI s o by: Date V
aanVContnaor .: .;t' Re-roofs
'. R "- HAZARDOUS MATERIALS DISCLOSURE
Wll the ascot t rftrchv'Iding oesupad tore or handl hmaidous ren al Type Of Roof
defined by the Capetian.Municipal Code Ch id 9.12.e d the Health and Safe
I s
Code Sat n 255J2O) q �`�
__.All roofs shall be insp cted pnir_to,any-roofing.matenalbeing 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 I&remove
emit hazmd sair co taminms as defined by theBay Area Air Quality Management
District ' all new materials for inspection. Applicant understands and will comply.with
all"non=point source regulations: .,'
I he e'rnd She hazardous m he requirements and", hipmr 6.95 of the
Colformula Health&Safety Code,Sections 25505:25533 and 23534,1 understand that
p Y Y it myrts nsibiliry do notify the
t e doing e requirements
current at must heLNat i pa -"-
occc ant of the requirements which man homed prior to issuance of a Certificate of
o"aPa°` Signature of Applicant Date
All f coverings to be Class "B"or better
xner or authorized agent em roocoverg ,I
.. •;. , :, �,._,.�_- ... _.:_._;,.. _ 'I -.. : '-- . : ._ .. ... .OFFICE.