03090043 (2) CITY OF CUPERTINO x
BUILDING DIVISION PERMIT CONTRACTOR TNTOMATIbN ';'.
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BUILDING ADDRESS: PERMIT NO03090043
701 NFWqQM AUR,
W NER'S NAME: PERMIT LSSUE DATE
DAVID CHAO
i E:
SANITARY NO. CONTROL NO,
ARCIRTEC IENGINEERo BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O Z LICENSED CONTRACT'OR'S DECLARATION lb Description
iu�FO 1 hereby.afErm That 1 am licensed..our provisions of Chapter 9(commencing oe5Cr1 p
j with Section]Efln)orDivision 3orthc fleancssand Professions Cn&MM in,license is
• w
an I.fall forceandaffecs' ADD 7 .1 S FTKITCHEN REMODEL
I y 2 License Clens Connector
a ��
y Dam F FF
££ ARCHITECTS DECLARATION
tK 1 undcrsmnd my plans shall be melts puM1lic rcrorJs
y 4 Licensed Professional
MAR 2 8 2004
t�� OWNER-BUILDER DECLARATION
Conte ON
40 hrechyaso affirm Thal I oro exempt from the Contractor's Co e:Any c Law fur the
my
.o O which ng reason.(Srofin construct,
r Business and Professions Code:Any tiny or county BUILDING
e$- which myuirm a permit r construct,alley,improve.rmw,h peorrit t m repair any structure
'iy pdt he isstensedcalsoat1.the the stimanl the roe Contractor's License
ned aw(Chapt col
a
that hcencinnsedpursLiOn7 h)ofDiviomnfoftheStsiness ndProfLew(Chapmr9 Sq. F[. Floor Area Valuation
G�G (cat he is
(commencingWithbasis for
of the Businessandon.Ayvi Code)or
� Net he is cacmpl therefrom end Ne baso for Ne alleged exemption.Any violation of 37529029 . 00
Section 7031.5 by any appliesm for a Permit subjects to applicant to a civil penalty of APN Number Occupancy Type
not more Nan fire hundred dollars($500).
❑I,as owner of the property,or my employees with wages as,their sole compensation,
will do Ne work,and the suunure is not intended or offered for sale(Sec.]044,Business — d Inspections
and Professions Code:The Contractors License Law does not apply to an owner of - 1 O Z — PIERS P
property who builds or improves thereon,and who does such worklonew f or through his
own employees,provided that such improvements are not intended reoffered formic.If, 103 — UFER
however,the building or improvement is sold within one year of completion,the rwner-
builder will have the burden of proving Nal he did not build or improve for propose of 104 - REBAR
sale')' 105 - ANCHOR BOLTS
0 1,as owner of the property,am exclusively contracting wife licensed contracmrs m 10 6 - SEWER & WATER
construct the project(Sec.7W,Business and Professions Code:)no Contractor's Li-
cemelawdoesnotapplyloanownerofpropertywhobuildsorimprovesthemon.ane. 2OZ — UNDERFLOOR PLUMBING
who contractsfor such projects with a conuactor(s)licensed pursuan 10 the Contractors
Bense Law. _ 203 - UNDERFLOOR MECHANICAL
Tem ezcmpl under Sec ,B&PCfor this remora 204 - UNDERFLOOR FRAME
war - Dam 7 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLAR TI
(� f:hereby affirm under Penalty of perjury one of the folowing declarations: 3O1 = ROUGH PLUMBING
t/V.
have wet maintain a Cenifcam of Consent to self-insure forworkerscompen- 302 TUB & OR SHOWER
senior,az provided far by Section 3]00 of fee Labor Code,for the performance of the 3 03 - ROUGH MECHANICAL
work for which this permil is issued.
❑I have and will maintain Worker's Crmpensation Insurance,am required by Section 3 04 - ROUGH ELECTRICAL
3]00 of Ne Labor Code,for Ne performance of the work for which Nissu
is permit is ed. 305 — FRAME
My Workers Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Cartier: Policy No.:
CERTIFICATE OF EXEM PION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or less.)(This section need not be completed if the Permit is ter one hundred Jnllms(SIW) 309 - EXTERIOR LATH
1 certify that in the performance of the work for which this permit is isucd.I shall not 3 10 — INTERIOR LATH
employ any person in any manner so as to become subject o the Workers'Compensation 311 — SCRATCH COAT
Laws of California.Dem
Applicant 313 - ROOF NAIL
Laws
NOTICE TO APPLICANT.If.after making this Cenificale of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation televisions of the Labor Code,you most
>Z forthwith comply with such provisions or this imair.shall bedeemed mvoked. 502 - FINAL PLUMBING ENERGY
tiOCONSTRUC7DON LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affirm Nat there is a construction lending agency far the Performance of 504 - FINAL BUILDING ENERGY
Lenders Name
x > thcwork sNamewhich Nispermit isiuucd(Scc.309],Civ.C.) 505 - FINAL ELECTRICAL -
t7 A
ZI Z Lender's Address 506 - GAS TEST
p 1 certify Nat 1 bew read this application and sate Nen the shove information is 507 - FINAL PLUMBING
(~ conal.l agree to comply with all city and county ordinances and mile laws relating to
�U building construction,and hereby authofiM representatives of this city to enter upon the MEC CAL
W above-mentioned property for inspection purposes.
4 gy
(We)agree to save,indemnify and keep harmless the City Of Cupertino against %FIN FI
liabilities,judgments,costs and expenses which may in any way accme against said City NG
in
of the greardi ng of
APPLICAeNTcUNDERSTANDS LANhis D WILL COMPLY WITH ALL NON-POINT Issued by: CF
WORKS Date
SOURCER ULATIONS.
Re-roofs
nemrc of Applic Commemr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will NO applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,section 25532(a)?
Ely.Ely. 1�JJJJNu All roofs shall be inspected prior to any roofing material being installed.
,
Will the applicant or future building occupant use equipment or Marta which
If a roof is installed without first obtaining an inspection,I agree to remove
7dinx
t harrier, nus air cnnmminana ss defined by the Bay Area Air Quality Management all new materials for inspection.
uin?
❑yes No
1 have mad the haaamuus materials requimmemu under Chapter 6.95 of the Cerror-
Health db Safety Crile,Secuons 255(15,25533 and 25534.1 undersand that if the building
not currently haw a anent,dial it is my Memorability m until'y the Occupant of the
uimmc81kts oM`mcif,emtpiarmismanaeofaCenlgca '(Occupancy. Signature of Applicant Date
vfYV—/— All roof coverings to be Class "B"or better v
Ow rirnJ egcm Dam