05030035 (2) CITY OF CUPERTINO .�s/.1z,xwwa s ,7„„ �s 'e' '�r
BUILDING DIVISION PERMIT ONTRACTOR,INFORMATION if
BUILDING ADDRESS: PERMIT NO.
RYAN HU 05030035
WN R' AM : PERMITISSUEDATE
E:
r SANITARY 0. OL NO.
ARCHITER/ENGINEER: BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION _ ]Ob DQSCfIpIIOD
w I Mroby affirm Nns
al 1 am licensed under provisions of Chapter 9(commencing
<E with Section 7000)of Divorce 3 of the Business ane Protcasiuns Coul and my leant is
�i LicenlacoCl and effm Lie.g ADD 177 '
5q_ (BEDRM) & REMODEL 320 (INTER. WALL)
z F a Date Contractor
W ARCHITECT'S DECLARATION
v�C 1 understand my plans shall'used u public records
DyU
uo G LdcmcJ Professional
3 OWNER-BUILDER DECLARATION
<f I hcrchy affirm Not 1 am commit firm Nc Contractor's License Law for the
isc following reason.(Sceuon 71131.5.Business and Prodsrom Cad:Any city of county
x m ff which requires a permit to enmuuet,old[improsc,demolish,or repairanystructure
us
_,o return,its inuanec.also requires the applicant forsuch permit to rile asignctistammcou 9 9000
—T that he is licensed pursuant anothepmmdem
visiooftheCantmetn'sLeLaw(chapter9 Sq. Ft. Floor Area Valu ficin
x
¢�9 that k is Ong with Satiate 7 ledfleDivisionr of doBusiness
ardrpt Professions Code)or
— that io u campy any applicant
li and de baso for be alleged eaempuon.Any violation of
Section thein by any applicantfor apermitsubjects the applicanttoacivilPenalty of 319jLtl*r00 Occupancy Type
not more Nan five hundred dollen(55003.
0 1,as owner or the property,or my employees with wages as their sole compensation,
will do the work.and thestmnao:is not inumbad reoffered fofaad(Scc.7044,Business Required Inspections
and Profession]Code:The Con,Ytor's LiceM1Y Law dams not apply to an Owner of q ,
property who builds or improves 0temon.and who does such work himself or through his
own employees.provided that such improvements are not intended mortared forsake.If,
however.the building or improvement is sold within one year of oompleuan,Ne owno.
Wilder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
1,as Owner of the proparrY am eaelurvely contracting with licensed cOnVOcbn to f /
convect Ibe pmjmet(Sec.7044,Business and Professions Code:)The Contractors U.
tems Law does not apply to an owner of property who Wilds or improves themon,and
who contracts for such pmjccu with a contracur(s)licensed pursuant to the Comractoh - L
License Law. '
lam ratio under .B&P C for this reason
Owners r— Data ) r
PWORkER'S COMPENSAVIGNaelitECLARATION
1 hereby affirm under penalty of pctjury ane of the following drelanyions:
ism and will maintain a Ccruficad of Consent to self-insure for Worker's Compere
on,as provided for by Section 3700 of the Lsbnr Code,for the Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation ImurWce,as required by Section
3700 of the Labor Code,for the performance of the work fin(which Nis pemiit is issued.
My Workers Compensation Iesuraaee carrier and Policy number art:
Came,.. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seelpar need not tecomplemd if t'permit is formic hundred dollars(tlp0
or IcssJ
I certify that in t'performance of the work for which Nis ppee it is issued.I shall not
mploy any penin in any maned u ro'come subject to1hc Workeri Compenuuon
Laws of Caliumja.Date
Applicant (
NOTICE TO I tCANT:If,after making th s Ccnificl&6f Emmlilion.you should
become mbjccs to the Workcr's Compcmation provisions of the Latin Code,you must
.,O forthwith comply with Web provision or this permit W deemed rowed.
ZN CONSTRUCTION LENDING AGENCY
[r I hereby affirm that them is a construction lending agency for the performance of -
a> thc work for which this permit is issued(See.3097.Civ.C.) ,
It3 Lroders Name
Lenderi Address
U Q 1 cenify that I have mad this application and sure that the above information is
14 r correct.1 area to comply with all city and county ordinances and state laws relating to
0(,7 building eOOSUOmimq and hereby authorre mprescmadce ofthis city to enter upon the
r� above-memimud property for impccuan purposes.
(We)agree to sero.indemnity and step bumless 0e City of Cupcnino against
F' Ta/] liabiliues.judgmenu,cosu and expenses which may in anyway acerae against set City
in
of the
of
his rmit.
CJ Z
APPLICANT cUNDER STANDStANO WIL OM PLY WITH ALL NON-POINT Issued by: Date
S URGE REGUL ONS.
G Re-roofs 07
nuurt of wain/144Contrai or Dare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mccupantamfe or handle hallolous material
as;dcfined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safcty
Code.Secuum 25552(a)3
❑Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will the apPlicantor fuwre Willing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
L ha.dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
ic"
❑Yes 0N
I have mad the bmardousmaterials w tommenu under ,Chapmr 6.95,fthe Califn, �_ I
ria Health&Safny C,dc,Sccuom 25M5.25533 and 25534.IunJcrstaM thuifl'Willing1 ^r I�fO /?, -i 1)
does net Currently haw a renN4 del ll la my responsibility m nW yy dC,ccupa t Of IIIe FJ�'/���({�
require cru which mu 'matt prior W issuance of ruficad of curmey Signature, Applicant G Date
Wer authorrrc cnt arc
All roof coverings to be Class"B"or better
C