04080062 (4) 71,
CITY OF CUPERTINO _ TT-
BUILDING DIVISION PERM ? CONTRACTOR Aja ""'"ATI
BUILDING ADDRESS: PAUL POONA PERMITNo.04080062
21 074 TAVTNA rT
OWNER'S NAME: PERMIT ISSUE DATE
PAUL POON
E: SANITARY 0 a CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
_ BLDG ELECT PLUMB MECH
L O p LICENSED CONTRACTOR'S DECLARATION
u 1 bemhy affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Second 70M)of Division 3.17 the Business end Professions Code,end my license is
d mfull famaandercecl REVISION--RAISE UP FLOOR
j$ License Class=s Lic.g
-ppp Dam Contractor NO NEW PERMIT ISSUED ORIG. #03070130
ARCHITECTS DECLARATION
1 understand my plans shall be,used as public menrds
;off Licensed Pmfessiona \/�
5 OWNER-BUILDER DECLARATION �rYV,a1
IMC I hmam affirm on 11. exempt from Jm Contmctor's :Any c Law for the
.ty
IMC following moon.Permit
1 7 onstr Business and va.demolish,
Cole:Any city m county
$(v which fcqulrca..emit re caresrthe alter,improv,demolish,me asig any structure
Prior a s licensed i p also requires the applicant for such permit to Bic s Law statement
ae (comma cngpursuanttotheProvisionoftheContractor'sndPneLaw(CnoPIm9 Sq.Ft.Floor Area Valuatio$115
Z
�N$ that M is exampt Section tBOB)ofDivisionbasison 3 of the Business and on.Any
Cooke)or
.. Net he 6 exempt therefrom and the basis for Ne alleged esemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
out mom than eve hundred dollars($500). P Y YP
❑l,as owner efthe property,or my employees with wages as Neirsole compensation, 32608027 ' 00
will do thewons sod Ne he Cons is nor intended ora w du es dat apply t oad',ovou of
and property
who
ons Code:The Contractor's License Law docs rot apply lf an owner of Required Inspections
propertywho buildsorimprat such improvements
and who doesaKhwork himmlfer through his
MR employee,provided pr suchimpm id within one
icamdWmeRemd formleline Owner.however.the building or improvement is told within one year of completion,Ne owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the progeny,am eaclusively contracting with licensed contractors to
cantina the pmjm(Sec.70m,Business and Profession Cade:)The Contractor's Li.
cense Law docs not apply m an owner of property ve
y who Wilda air impros Jon
mm ,and
who contracts for such projects with a conmKmr(s)licensed pursuant 19 the Contractor's
as Jw.
Wa
s /pit underf ,B&PCfor Ni rcuon
o�ael I�
WO Data
'S COMP R)N DECLARATI
1 hereby affirm under penally of pepury one of dm following declarations:
have and will maintain aCmsiOam ofConaenuo self-osum for WoricesCompen-
sation.as provided for by Section 3700 of the labor Code,for Ne performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of lie Labor Code.for the perfurramec of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit is Future hundred dollars(SIM)
or less.)
1 certify Not in the performance of to work for which this permit is issued,l shall not
employ any perm.in any ersnaztobCcAme subject of W %Corppense0on
Laws of Califomie ditto /rl l !d
Applicant �� I
NOTI E TO APPLICANT-:SIf.after makhig this Cc am of Exemption,you should
bccoat subject m the Worker's Compensation provisions of the labor Code,you must
.J O forth r Imply with such provision or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
'nom I hereby affirm that therm,.construction lendingagemy for the peffarmmea of
;e the work for which this Permit is issued(Sec.309?,Civ.C.)
W A Lender's Name
,7. z Lender's Address
V 0 I certify out 1 have read this application Rod sum that Ne above information is
IL F coned I agree u comply with all city and county ordinances and sum laws relating to
OV building convection,and hereby auNorim mpma=Wivu of this city a enter upon Ne
WU .hove-mcn kmcR1 property for lost cdon purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
h liabilities,jadgmenu,costs mcimpensa which may in any way Keme.&.lost said City
V,'� in consequence of Ne gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE �6/
R�ATI(�I � Q ���
��//�`//om __jY/yy�\ — Re-roofs
sign of APPlican omrDOU V
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ince applicant or(mum building e.Chapter
or handle Health
material
n defined io the Cupertino Municipal Coda,Chapter 9.13,and the Hcaith and Salary
Cole,Section 25532(.)?
❑Yes HI�/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
t hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
victT
C]Yes FTI Nu
1 have mad the haamdous materials requirtmenu under Chapter 6.95 of the Califor-
maHcalth etyCodc,Secdan25505.35533md2553a.Iundcsstandthatifthe Wilding
Jars n u dy haw t.Nas it is my mspenihilily u nadly the acupant of the
moot me hi t mctttismahmc.r.Ccnifma roccVepgy. Signature of Applicant Date
Owner arautharizced spent s //LLAT All roof coverings to be Class"B"or better