05040056 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTORtIN.FATION
ORMb.
BUILDING ADDRESS: A TO Z GENERAL CONSTRUCTIO ."MIT"°05040056
l ; 84c; RRnnKwELT, DR
ER'S NAME: !'ERWTISSUE DATE
FRANCIS CHEN
ONE: SANITARY N0. CONTROL NO.
(408) 926-5313
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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u LICENSED CONTRACTOR'S DECLARATION
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as
m I barely affirm WI 1 em Ihevcd under provisions of Chapter 9(commencing Job Deserip[iFINALE...
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_� with Section 70(10)of Diviaion JoflMBusircer and Professions Code.end mylicenss is
mrunmm anaerteek D g ADD 495 ' (MS BEDRM/MS BATH)
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J AR HMICES DECLARATION _./. //o_ 7yyrs/
I understood my Plans a W toed u pfblic records
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OWNER-BUILDER DECLARATION Rj I� � �v
.�n 0 1 hmaso affirm that 11. exempt Bearers an the Colors Co License ty o fur the ® y�B,�v
La 0 following mason. ermit t II131.3, lter. and Professors h.ac:Any city s county
m which myuiru a Permit m ennswcl altar,improve,demolish,m repairany structure
prior to i%issuance,aleo martini dieapplicant for such permit to file.Signed sulemere
that he is licensed putmant to live previsions arlhe Contractor's Licemc Law(Chaplet 9 Sq. Ft. Floor Area valuation
Y1-0 (commencing with Section 7")of Division 3 or the Business and Profusions Cmlc)or
i $ that he is exempt thcrefmm and the basis for the alleged exemption.Any violation of y�{ta/n�'y/K
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of 3682(.YJa 1.LLp WletO O Occupancy Type
not mare thm five hundred dollar(5500).
❑I.Ua ncrofim mpcny,amyemploytt wiNwsmuN irmlccompenudon,
will do IW work,and the swcture is not immmdee orofremd fonale(See.7()U,Business
and Profusions Code:The Contractor's License Law does not apply w an owner of Required Inspections
property who builds or improves Iheeon,and who dassuch work himself or through his
awn employes,provided than such improvements arc not intended uruffered for sale.If.
however,the Wilding or improvement is arld within as year of completion.Ne owner-
builder will have the burden of proving that be did no Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
connmet the project(Sea 7W,Business and Professions Cade:)The Conlracter's Li-
eenae law doca not apply man owner of property he WiIdS to Improves Narcan,and
who contracts for such prejeets with a comracwr(s)licensed pursuant in use Canmactor's
Lcarm La-
1 am exempt under Sec. B A,P C for this reason
cr Dare
WORKER'S COMPENSATION DECLARATION
1 hereby afrrred under penalty of perjury ore of the following declarations:
1 have and will maintain a Cceme caof Consent m self-insure for Worker's Colorer-
\ .tion,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
3700 millet labor Code,for the pcRormance of the work for which this permit is issued.
My Worker',
�Cmer enation In...carrier and Policy number am:
Camer:k �J/ �E $�.N1J.Y,S^L�Policy No.: lYB.S
GERTIFTCA O'IE FEXEMPr10NFROMWORKERS'
COMPENSATION INSURANCE
(TTisaccuon recd not sccompleted iflle permit is Were hundred enBars(5100)
or irsa)
1 cenify that in the Performance of the work for which this permit is issued,I shall not
employ any person in any manner an as to become subjut to the Workers'Compensation
Laws of California.Data
Applicant \
NOTICE TO APPLICANT:Ir,after making this Cenifcae of Exemption,you NouW
become subject to the Worker's Compensation previsions of the Labor Code,you most
.JO foMwith comply with Such provisions or Nis permit Shall W deemed revenue.
z '--' CONSTRUCTION LENDING AGENCY
I hereby affirm that ft.I,.emstructmo lending apermy for the perfinermce of
Ix� dm work for which this Nook is assured(sec.309],Cie C.)
W A Lender'.Name
Z Lender's Address
V C) 1 comfy that 1 have mad this application and sate den the above information is
ly -i
i correct.I agra to comply with all city and county ordinances and sue laws retailing w
0O building construction.and hereby authome representatives of this city to enter upon the
r W above mentioned property for inspecuon purlwms.
f~ r'1. (We)agree to save,indemnify and kap harmless the City or Cupertino against
,,I Liabilities,judgments.costs and expenses which may in anyway accrue,against mid Ctry
V z
APPLICANT CUNDERSTANDS IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU ONS. 7�7/�
�—� I Re-roofs
Signature— o��idContraemr �m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the,applicant or future Wilding occupant store or handle havardaus material
as dented by dee Cupenina Municipal Code.Chapter 9.11,and tW Health and Safety
.Semen 25532(o? All roofs shall be inspected prior to an roofing material being❑yes El No P P Y g g installed.
W!1 the. scant or future buildingt use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hawarmmx au contaminants a defineh the Ba AreirG r Management oal it s all new materials for inspection.
rSVlfl?
❑Yes El No,?
T have mad the havallous maedals regeimmen s under Chaperii.95 of the Califon
rain Health St Safety Code.Seedons15505.15533 and 25534.1 undersand thetif Ne building
does not time ily have a heart.that it is my responsibility to notify IW occupant of the
requireme wWchmu malpdawl55uanceafaCenthmeora pan -Signature of Applicant Dale
v� �l �0� All roof coverings to be Class'B"or better
Owner ser amhomcd egcm Dam