02120019 (2) CITY OF CUPERTINO - -'-
BUILDING DIVISION PERMIT CONTRACTORIINFORMATION
`. .-r,;:
I BiT[[Q)24A16EsSLEARCREEK CT PERMIT NO 2120019
T-E "%R6E & JOANNE HSING APPLICATtP12Sp�TY2002
PHONE: SANITARY NO.! CONTROL NO.
ARCHITEC IENCINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
t� 0
loo, LICENSED CONTRACTOR'S DECLARATION
Gwi F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Deserip io
<w with Section 7faR)ofDivision3oflhe Business and professor.Code,and my Hermon, ADD 317 SQ. FT.1-ow in full force and effect OCT 2-U 2003
F pLicense Class Lis. b 2 L {gJ
Dam Can.
AR into]]use DECLARATION �'�'��
O public records
w I understand my plain shall ha used u DECLARATION
a.U
LLO� Liccnttd Pmfcssionul
OWNER-BUILDER DECLARATION
F I hereby affirm that 1 am exempt from Ne Contractors License Law for the $150000
p�s0 followingreamn,(Section 7031.5,Business and Professions Code:Any city orcoumy
� which requires a Permit to construct.alter,improv,demolish,or repair any structure
prior to its issuance,also requires she applicant for such Permit to file a signed statement
Q�Qx�x< that he is licensed pursuant In the provisions ofthc Contractor's License taw(Charier 9 3S$6H18IEIQ22A@(D Valuation
81-$ (commencing with Section 7000)of Division 3 of the Business and Professions Cork)or
�.- that he Is exempt thcmimm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicun for a permit subjects the applicant to a civil penalty of iUAP11NfiWAAIDATiUN Occupancy Type
not mom man five hundred dollars($500). 102 - PIERS
❑I,as owner ofine property,or my employees with wages M their sok compensation,
willdothewoh.sndthestmctureisnot intended or offered for We(Sec.70W,Business UPER—
and Professions Code:The Convector's License Law does not apply to an owner of 1 0[} REBAR Required Inspections
property who builds or improves thereon,and who does such work himself or through his
man employees,provided thassuch improvements am not intended w offered forsale.If. 105 — ANCHOR BOLTS
however.me building or improvement is sold within one year efcamplether,the owner-
In106 — SEWER & WATER
uilder will have me burden of proving that he did not build or improve for purpose of
nla.1. 202 - UNDERFLOOR PLUMBING
I,as owner of the property,am exclusively contracting with licessed contractors to 203 - UNDERFLOOR MECHANICAL
n the pro' .70,14,Business and Pufersiow Code:)The Consomme,Li-
censeLa sno pply anownerofpropertywhobuildsorimprove.Mancon,and, 204 — UNDERFLOOR FRAME
when.Lawes ,rs cu 'th conwnor(s)liccnsed purwammdm Contractors 11 205 - UNDERFLOOR INSULATION
lam .B&PCfar I,reses^ 301 - ROUGH PLUMBING
302 - TUB & OR SHOWER
cECLA N 303 - ROUGH MECHANICAL
Ihem affirrunder rams yofNquryone ofthefollowing decimations: 304 - ROUGH ELECTRICAL
❑Ihavc and wit n cnificam ocmusanuo self-Insure for WorkiaACompen-
sation,u provided for by Section 37M or me labor Cuda,for the Performance of the 305 — FRAME
work for which this Permit is issued. 306 — HOLDOWNS
❑1 have and will maintain WorkcYs Compensation Insurance,as required by Section 3 07 - INSULATION
3700 of me Labor Cade,for the performance tuition work for which this Pewit is issued.
My Workers Compensation Insurance carrier and Policy number am: 308 - SHEETROCK
Carrier, Policy Na.: 3 09 - EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This section need not M completed ifft pcwlt is fmome hundred dollars($100) 311 - SCRATCH COAT
onlCss) 313 - ROOF NAIL
I cenif tint colo a cc of the wn k for which mit Permit is issued,I shell nut 501 - FINAL ELECTRICAL ENERGY
c yany ne t mmnxelyduiothc WorleeritCompensation
aws of Caifi 1 V/w 502 - FINAL PLUMBING ENERGY
NOT`° A r a shuCcnificaua(Excmplion,ynuahnulJ 503 - FINAL MECHANICAL ENERGY
co )c cWAcr's mPcusmionprevisionsol'The Labor Cole,youmust 504 - FINAL BUILDING ENERGY
,0 forthwith comply with s tons or mit pewilshall be deemed revoked.
0 505 - FINAL ELECTRICAL
.N.
CONSTRUCTION c ON LENDINGng agent
[r kfrchyaRwNasmcmissued ee.Tonlendingagcncyfanhcperfuwaneof 506 - GAS TEST
14 — thcwnks,rwhichthispcwitisiuucd(Rcc.31N7,Civ.CJ 507 - FINAL PLUMBING
6Wi O Under's Name Lndranddre: 508 —
FINAL MECHANICAL
U0
U O 1 renee that I have read this application and atam thin she sham information is 509 - FINAL GRADE
(, correct.I agree m comply with all city and county ordinances of mJ slam laws r upon t e
building conswnion,and hereby authnria rcprcxnutivcs of this city mcnmr upon the 5),,G\ FINAL PLANNING
above-mentimund property for inspection purposes.U
4� ran
Ppe P PP 14 - FIN IC W RKS
ve,indemnify and keep harmless the City of Cupertino against
by sts and expenses which may in any way accme against said City
C.) in eran' g h PermitAPPST N A D WILL COMPLY WITH ALL ONPOINT Issued by: DateUN Re-roofsn ' nF°DOUR MATERIALS DISCLOSURE et 01C Type of Roof
orfutore building occupant stem or handle hasaedous material
A'ftc`rc'by
the Caperinu Municipal Code.Chapter 9.13,and the Ilealth and Safety
.learn 1553q.)'' All roofs shall be inspected prior to any roofing material being installed.
1IFF0Y.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamrdous air conmminanu as defined by the Bay Arca Air Quality Management all new materials for inspection.
Di aricrl
❑Y No
I
an the losadenrs xmquiremenu un&r Chapterfi95of the CaliRn- '
ry Sccdnns i1153. 31end25534.IundeatandthatiftM buildingy ha m t y responsibilitymnotifythe ant•hm cion Itl' anccaracenireatearQaap Signature of Applicant Date
2 0� All roof coverings to be Class"B" or better
caner or e"Meri ed agent Oatc