02010001 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10167 COLBY AV MICHAEL CHIkL 02010001
OWNER'S NAME: APPLICATION SUB DATE
MICHAEL CHIN 01/02/2002
• PHONE: SANITARY NO. CONTROL NO.
O re0 ZO ARCHITECT/ENGINEER: BUILDJUITPERMIT INFO
z u- BLDG EL PLUMB MICH
L1
¢d
z z Z- 1 hereby affirm Na LICENSED amONTRAd under provisions
DECLARATION Y(commencing Job Description
O N_' pr vino per g
P-_u with fallfrpeandef Division3of she Business and Professions Code,an0 my license RE-CONNECT METER
zY-< is in full force tnd effect.
K O u Date Class Lic,p t -
Doc ContSDECLAr
w LL n ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
f3T
n d p O Licensed Professional
x o a OWNER-BUILDER DECLARATION
st m 1 hereby affirm 1 bre exempt from the ContractorCI License Law for the
F' < following mason,(Section
an]01 L5.Haziness and ProfessionsonsCale:Any city m ccumy
E a which requires a permit to report alar,improve,demolish,or repair any structure $1000
a 3 m -prior to its issuance,also requires the applicant for such permit to file a signed statement
Nat he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9OOfValuation
mornmencingwish Sccixxi_7 W)
of Division J of the Business and Professions Code) lzA{eap l I � r,,;
or that he is exempt therefrom and the basis for the alleged exerrpdon Any violation `4k V V
of Section 7031.5 by any applicant for a permit subjects she applicant to a civilpsralry _ �.7�m�C
of not mom than five hundred dr,frox S500), 304'? ELECTRI AL�f'• I Occupancy Type
❑1,as owner of the properly,m my employees with wages as their sole compensation,
will do the work.and the structure'is nor intended nr offered for sale(Sec:7064, RINAT RIRCTRT AL ENERGY - - - -
Businevs andTnifessions Cale:The Contractors License law does not apply to an 505 - FINAL ELR€9ito�_�Li%Epctions'' ." -
twom,of properly Who builds or improves marten,and who docs such work himself
or through his own employees,provided mm such improvements arc not intended or
or szle:If,however,the building or im--'_ "'I is sold'wi'hi'n'd a __r_f - -"'-"'_.,___...._.".. .
orepJ g provemen n yearn
completion,the owner- ilder will have Ne burden approving that he did not build or
improv ,mU o soled.
owI',odmm property. exclusively contracting withf sed masers to
c r a he p l n(S ]DLI B se dP f Cod.) e C tactors //
License La doe. t pap[ per of p pent h Wildripp p tarpon,the
C .and who cora acts f h framers.with t enor(sl 1 tt d p the _
G 1 1 License uan '
❑1 m< rept Qd t 1` B&P Cfar enis..on ,iI
Ousbar
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pemalty of perjory one of she following declarations: .
❑ I have and will'mainp,in a Ceoificme of Carrier' m.olLinsme for Worker's
Compensation, as:provided for by Section 3]00 of 'he Labor Cade:far the
_ > performance of'he work for which'his permit is issued. .
O 1 have mid will maintain Worker's'Compmmiioh loeuance,as required by Section
37O0'of the labor Code,for the performance of'he work for which this Penni'is
issued.My Worker's Compensator Insurance carrier and Policy number arc:
Came K t
ie CERTIFICATION OF EXEMPTION RANO WORKERS'. _ I f t x ♦.'°.. `t{t j !s�'a la w
- COhIPENSATION INSURANCE"
J.') n need not be ample'eJ if the permit is for one hundred dollars -
(5100)or or Icss.)ulo
1 certify n th p'f ' oter k h ha.mspe usissuer1 a "
ih sp en employ any pe son n any manna so at to becamesubJecs to the Workers -
Compemaion Law.c of California.Dam
Appliceir
•NOTICE TOct1.APPLICANT.IL after Compensation
Certificate fExemption:def6.should
mail
'become hwithc ropy the such
Come,or
is pr.it'ha of the deemed
Cole:ymu must
Q forthwith comply with such previsions or[his permit shall be deemed revoked.
-^F I ` that in RUCf10N LENDING AGCNCY' 'pimps
I hereby hickffirin do,pe re izs comuuamn Icndmg s. .) r the performaece ,
If she work for which mu pennn is issued(Sec JOY].Civ.C.1
� z Lc d AJJrezz
r,
1 eagree ma[1 have reed this application any sate that the above information is
corren.l ban,o comply with all city and county orduuncee and sale laws relating
Q_fJ
or
bu.... .ema,uaionand hereby authorise'rcprmenmtivesbf this cirymemer upon
th b f d apes p rpap
[moi 1 eWju gree z �demofyandkeep haml the way
f 1 peninarago ns'
m
liabilities,judgments, :'. J c pcnu which y,'n au Y'cc gainzl zaid
U ,Z CnOT1or .ey f egmn Bolt pc 1.
SAP I1.� J?UF rA�r A/y[/y L COMPLY WITH ALL\ON-POINT -
ig Ulm OOS Issued b �-
1. y: Date
gn art of Appl cHAC taco Dale Re-roofs /
HAZARDOUSrMATERIALS DISCLOSURE
Will Op ppl cant f' holding arae pans s[oa or haMl hazardous 'nal --Type of Roof
m asdefcdbytheCpen M palC eChpt 912 and the Health dSafetyyP " "� "' """' """ ^�•" - --
'Code 5 1 on 2551_0
°Y I. _ All roofs shall be Inspected prior to.any,roofing,material being installed _
'e curl n ar m- e b '- e-t " If a roof is installed without first obtaining an inspection, I agree to remove
m'hax tl m' '. df dbym Bay A qA QtItYM1I dgemm g P g
°i m°' all new materials for inspection. Applicant understands and will comply with
oY
all non-point source regulations. "
Ihv 4d'the himr l ' ,
q ' m nti d do Cb pt a 95 1 the
California Health&Safety ode.Sections25505.25533 and 3553a I understand that
f the
building aces no'cumndy have 't tl mY .p 'tilty nno'fy me
per. [arf them wheh u -
Prom 9u rc n yu� p o is e f Cenifi to of "
O have
Signature of Applicant Date _
Owner or authorized agent Date All roof coverings to be Class "B" or better '
OFFICE