03020101 (2) CITY OF CUPERTINO 3
BUILDING DIVISION PERMIT CONTRACTOR�INk'OMATI®N ?`
JC
MINGADDRESS: LEH-FEN WANG PERMIT NO.
NER'S NAME: PERMUISS E ATE
LEH-FEN WANG
ME; SANITARY NO. - CONTROL NO.
HITECTBENGINEER: - BUILDING PERMIT INFO
BLDGELF.Cr PLUMB MECH
0 0 o I�
X00 LICENSED CONTRACTOR'S DECLARATION
I harchy af0rm Nat 1 am licamal under provisions of Chapter 9(commeneing Job Description
with Section 7M)of Division 3 of the,Business and professions Cade.and myliccns is
no mu farm.na enea REMOVE WINDOWS OPENING & R13FJL�{]-N�
[�z Lima.Clssm Liu.. hk�tl Cj r�
Dam Contractor BACK TO ORIGINAL CONDITION
ii ARCHMCI'S DECLARATION
�y K 1 understand my plans shall he used as Public rccsudt MAR2 n
0 2003
g iso t; Licensed Profcuioul
OWNER-BUILDER DECLARATION
1 hereby an,.Nal 1 am exempt from Its,ConlAmars License Law for the
Sull
00 folinwess ing reason.(Section 7031.5,Businand Professions Code:Any city or counq
k$� which requiem a Permit to contract,aper.improve,demolish,or repair any structure g V V
nZ prior to its issuance.aBa rcquiru dm applicant for such pencil o BIc a signed statement
that W is licensed pursuant to the provisions of the Commoor's Limnse Law(chapter 9 Sq.Ft.Floor Area Valuation
mcZo (commencing with Section 700M of Division 3 of the Business and Professions Code)or
..
that he B exempt thsafrom and the basis for Ile alleged exemption.Any violation of $500
Section 7031.5 by may,applicant for a permit subjects the applianl to a civil penalty of APN Number Occupancy Type
am more then 0w hundred dollars(M). Pane Y YP
❑I.as owner of the property,or my employee with wages ss their wk compensation, 35923006 . 00
will do the work,and she structure ts not intended or offered faille(Sec.70".Business
and Pmfesshom Cade The Combustion Limine,Law does not apply to an owner or Required Inspections
progeny who builds orimpromilancon,and whoducasahwurk himself orthrough his 101 - FOUNDATION
own employee.provided thatruch improvements art notintended or offered forsale.If, 102 - PIERS
Wilder
however,the building or improvement issold within one wv of complains,the owner-
Wilder .will haw the burden or proving that bo eta not aril or improve roe purpose of 103 — UFER
ale.).
O 1.u Owner of the property,am exclusively commucting with licensee contramma to 10 4 - REBAR
consumer she project(Sec.7066.Business and Pmfessinns Code:)The Conteacmri LL 105 - ANCHOR BOLTS.
tense law eom,not apply man Owner or property who builds or improve thereon.and 106 - SEWER & WATER
who contracts for much pmjettt with tra
n conctsr(s)licensed pumuant so tie mr
Coamarm
Lt en.law. 202 - UNDERFLOOR PLUMBING
ion eaemp nes see. ,B�Pcr Nlm an 203. - UNDERFLOOR MECHANICAL
Owhe. RXER'SO MPENSA NDECLARFTII� 204 - UNDERFLOOR FRAME
thereby.mmtunder penalty ofpernryamofthe following eecl.ntiw: 205 - UNDERFLOOR INSULATION
I have and will maintalO a Cedmam ofComemto rdr-Imum to,WarkeraCooper. 301 — ROUGH PLUMBING
sasion,as provided for by Schon 3700 of the labor Code.for the performance of rot 302 - TUB & OR SHOWER
wart a which mi.
uaturnaissuM. 303 - ROUGH MECHANICAL
37 I hew and will Code.
wmarfa Compensation Insurance,ss required by Section boud.
My( me work milia caw. 304 - ROUGH ELECTRICAL
My Workers Compenutinn Insurance carrier and Policy number arc: 305 - FRAME,
Coerce CERTIFICATE OF EXEMPTIOPoliN FROM WORKERS' 306 - HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
or ksx) -
(Tbk¢eticn need not bo completed if the permit Is foram hundred authors(SIM) 308 - SHEETROCK
I¢oily deadx pc
I-IrrOwe Na aneOf comic for which this Permit is issad,l shall not 309— -EXTERIOR LATH
employ any nenon lna annermossmxs mmy t. lhewmtui Cmaa'n1m1IOn .310 — INTERIOR LATH
LJWm of Califymid. '2
Applicant 1 g - Q.,, IA 311 - SCRATCH COAT
NOTICWTO APPLICANT:IL aper making this Certificate of Exemption.you shmW 313 - ROOF NAIL
become--him I-the Wmka's Compensation provisions of we Labor Code,you mus,
J,Z, Forthwith mmplYwith much Provisions orthis Parrett sh9lxdiamond revalued. 501 - FINAL ELECTRICAL ENERGY
? O CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
F� I far
rwhichithi Nat Nem isacomw,.3M7,loading agency l'm tie per(ormancc of 503 - FINAL MECHANICAL ENERGY
C,,,� Lndwork(m which this permit is issued(Su.J09'r,Civ.CJ 504 - FINAL BUILDING ENERGY
W A Isnemk Namc
Uz <ndermaaaesm 505 - FINAL ELECTRICAL
L)Q I.nee Na,I have rue Nis application end relate Nu Nc shove iws rmuing o
crosn.I.gra,o amply with all city and county ordinances and suis laws slating m 5 06 - GAS TEST
0U Wilding conswetion,and lumbysuborimmpresentativesofthis city toon=upon Ne %FIN PLUMB G
W about-mendomd property for Wittman purposes.
(We)mg.m taw,indemnify and keep harmless the City of Cupenitm agaiet I L
..x h liabilities,judgments,cases and expenues which may in any way accrue against said City In consegnencc of Ne gaming of Nis permit.APPLICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON-POINT Issued by: NG Date
SOURCERE A N
- Re-roofs NAL UBLIC WORKS
LL rcorA tanV nbacmr Dam
HAZARDOUSMATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant Rom or handle heatdaus matenal
as defsned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ade,Scab..25532(a)7
ne.
❑Yes w1 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant tau ryulpment or dcviam which If a roof is installed without first obtaining an inspection,I agree to remove
DtsIttbeTardous air contaminants u defined by tiro Bay Asa Air Quality Management all new materials for inspection.
❑Yet <No
1 have read Ix Weardtesmmerialsrequircments under Chapter 6.95 arms,Califor-
niaHcet"Safely Coda.Seldom 255115.25533 and 25534.1uMcrvarae thmifmc building
does not curroaDIly low a tenant,out it u My pandbility w no the occupant Of an,
caI e a x pnarmi anr.ccoirtcateaf ty. Signature of Applicant Date
ioT�`in, � �g o
Owner uramhonsed agent = D,m All roof coverings to be Class"B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work(complete section below)
Contractor Address/City Phone# State License # Type of work to
be performed
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse s'de)).. JJ
Property Owner's Signaturee-Z;>d, D� 2 ` — D j
Job Adds�st�9�1 0 Permit# b
Any chan✓✓ges to the information provided on this form shall be sub Red to the City of Cupe ino Build
Department.
r ii
ITCity of Cupertino Building Departme
CITY OF �.
[ O 10300'rorre Aveo
C U P L T I N O Phone: (408)777-3228
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county..They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes,workers' compensation insurance, disability insurance costs, and unemployment compensatioi,
contributions.
There may be financial risks for you if you do not carry out these obligations,and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under state law, contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit, erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
.Building Department,
City of Cupertino
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