05030097 (2) CITY OF CUPERTINO * �uawe.
BUILDING DIVISION PERMIT TOR"INFORMATION
BUILDING ADDRESS: PERMITNcb5030097
1146 DE V
ER'S NAME: PERMIT ISSUE DATE
SHU-CHEN HSU RU-PING LIN
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o O LICENSED CONTRACTOR'S DECLARATION
I bercby affirm that I.m licensed under provmmna of Chapter 9(commencing Job Description
with Section 7")of Division 3 of de Business and Professions Code,and my license is
„ to Full ceanderrm ( ADD 493 ' (MSTR BED/BATH)
p w�o, License Class Lie.a
z� Dam Comracwr REMODEL ENTRY PORCH
pp AR recordsTSDECLARATION CONTRACTOR: GLOBAL CONSTRUCTION
zt K 1 understand
W
anJ my plans shell used u public records
Dau
o G Licensed Pmfcssional
OWN$ 3
d<Y ER DECLARATION
I hereby
I am exempt from the Contractor's
s License law for the
Q O following mann.(Section 1031.5,Business and Profeaiom Calc:Any city or County
y$ which acquires a permit to construct,.Iter,improve,dconorsh,or repair any nmetum
Fieprior to its issuance.also requires the applicant for such Permit o file a signed statement
that be is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
SFO (commencing with Section 7100)of Division 3 of the Business and Profusions Codc)or
y $ that W is eumpt demfrom and the basis for the alleged cscmption.Any violation of $57069
Section 7031.5 by any applicator for•permit wbjecu the,applimnt to a civil peachy of APN Number Occupancy Type
not mom Nae firs hundred dollen($500). p y Yp
1,as owner of the property,or my cmployow with wages as Heir sole eompeneadon,
will do the work.and WarrucW.isnot mucromd or offered for cam(Sec.7014.Business eCliO
IO
'
DICedDS
$
and Professrom
Professions Code:The Concrt does Liceom law not apply to an owner of Re q d' , p 07s
property who Wilds or improvmthercon.and whadoessuchwosk himselforibrough his
Own employees,provided that such improvements are not inerded or offered for sale.If.
however,the building or improvement is sold within one year of completion,the the Wrowner-
ve dcn of proving that he did not Wild or improve for purpose or r
sale.).
1,as owner of the property,am exclusively contracting with licensed convacwrs to
builder will ha1(J
comwct the pjcct(Sec.7004,Business and Profusions Code-:)The Contractor's Li.
come law docs not apply to an owner of property who Wilds or improves themon,and U
who contracts for such projects with a contractor(s)licensed pursuant to the Contnetofs -
License law. - t
❑I am exempt under See ,B&PC for this masonCr
Data L s f
WORKER'S COMPENSATION DECLARATION c'
1 hereby affirm under penalty of perjury one of the following declaratiom: -
1ban and will maintain aCcnfiIC of Consent to self-insumfor Worker's Compcn-
action.as provided for by Section 3700 of the labor Code,for the performance of the
work for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance,w required by Section
3700 of the labor Code,for Nc performance of Ne work fm which this permit is issued.
My Workers Com emaumn Inwnna eartier and Policy number are:
Cartier. PolmyNo.: 'f l� 3 D001 ' SS
IFICATEOFEXEh ONFROM ORK ERS'
COMPENSATION INSURANCE
(Thu section need not he completed if thc Permit is formic hundred dollars(SIM)
or leas.)
1 cenRy that in the perfamtanm of the work for which Nis Permit is issued.I shall not
employ any pawn in any mannerw as in become subject to tM Workeri Compcneauon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,tort,making this Certificate of Exemption,you should
become subject w the Worker's Compensation provisions of the labor Code,you most
.,Z foMwith comply with such provisimis or this permit shall be dccmcd onism.
z O CONSTRUCTION LENDING AGENCY
[r I hereby affirm that Nem is a construction lending agency,for the performance of
W' the work for which this permit is issued(Sec.3097,Civ.C.)
1141 0 Lenders Name
= Z Lender's Address
V O 1 certify has I ban read this application and soma that the(chore information is
U.f-' corset 1 agree to comply with all city and county oNinuuxs and state laws relning to
O V building construction.and hereby amhodm representatives of this city to enter upon he
�a above-mentioned property for inspection purpoes.
(We)agree to save,indemnify and keep humleu the City of Cupertino against
F'h liabilities,judgmcnu,costs and expene..hich may in any way acoruc against said City
U Z in eomequmcc of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL 10
Re-roofs
Signature of Applicant/Cm uraemr Dee
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne-applici m or future Wilding occupant store or handle hazardous ma trial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Hcalth and Safety
dc.Section 23512(a)?
❑Yu 11 No All roofs shall be inspected prior to any roofing material being 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 to remove
emit haurdous air contaminants as defaced by Ne-Bay Area Air Quality Management all new materials for inspection.
Distrix?
❑Yea ON.
I have mut the ha eaNsms materials requirements under Chapter 6.95 of IW Califor-
nia Health& m Safety Cook,Seeuo25515,25533 and 25534.1 undersand that if the building
docs not currently basso.tenant,Nm it is my responsibility in notify Ibe uacvPam of the
rcgoim' hi Meme,prior tosatiammOf.Ccmr,,.¢of e470 Signature of Applicant Date
Owner or authori'red aFcm Date-
All roof coverings to be Class"B"or better