04070147 (2) CITY OF CUPERTINO '"° ' Ta 11 N
BUILDING DIVISION PERMIT OI�iT—AA�.C." OltINTOIWATION �, - -
BUILDING ADDRESS: """'04
""'04 0 7 014 1
OWNER'S NAME: PERMIT ISSUE DATE
IL ROGER LEE
E: . SANITARY 440. ri� CONTROL NO.
ARCHITECTiIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
coo LICENSED CONTRACTOR'S DECLARATION
a 1 Mmby arctm that 1 un licensed under provisions of Chapter 9(commencing Job Description
< IN Se.d.m 70007nf Divlai*n 7 of the Businessand Prefealom Codo,and my]am=is
^� in full to.md.ffat.
;1? Lkeru.Cws% Lk.R ADD 1234 SQ.FT. /REMODEL
Date Crammer KITCHEN REMODEL/BATH RM RELOCATION
ARCHITECTS DECLARATION
1 umhrsund my plan shall be used as public records
`ua Licensed Prows al
OWNER-BUILDER DECLARATION
X I haeby alarm that 1 am exempt from the Contowtor's License Law for the
sO O fallowing moan.(Section AO 1.5,Business and Profession Code:Any city or county
.�g V which requires a permit an cnwtroc4 alter,improve.dcamich.m repair any structure
t- prim in its issuance,also requires the applicant for such permit to file a signed sutement
< Net he is licensedp....attotheprovisionso(NeContractoisUcCame ^w(Chapter9 Sq.F[. Floor Area Valya�t�yg000
zC9 (commencing with Stadion 7000)of Domino S of the Businms4nd limitations Codt)or r
3.. that he is exempt therefrom and the hands for the alleged exemption Any viahman of
Section 0
1.than Oboe hu applicant
ppliced aanitfaralars m7.it objects tike applicant ro smil paiahy of APN Number Occupancy Type
not[:j 1,as awnm of dte property,or my employees with wages as their min compensation, 36611120 . 00
will na the, at and tht swnurt isnot intended or offered far sale(Sa.7044,Busimv
and PrefeWon Cade The Continence.Liaise law des rot appy in an owner of Required Inspections
propertywho Wmidserimproves theean,and who doessuehwor ihimselfm through his
.we employees,provided Nat such Improvements are not Intended moRered for Wes IL
however.the building or Improvement is sold within am year*(completion.we owner-
builder will hoe Ne bund..of proving that he did at Wild or improve for puryo¢of
tile.).
IypA�1,e.owner of the property,am exclusively contracting with Tinned connection to
Eanwa Ne pmjat(Sec.70th,Business and Prefesdon Code:)The Contractor's Li.
whoa Law dmf not apply as anof progeny who built rovea Norton.
or imPand,
who common for such projau with
a a cantrsoror(s)liaised purswnt to Ne Conlnnoes
License.Law.
❑lam exempt untler Sa. ,B&PC far thin rescan D
%440�
.. r— Date . ?OO
WORKERS COMPENSATION DECLA ION
Ihe.by aRifm under penury of perjury aw afth awing dalantionr. c
,have.nd will mainW n a CmlBCak of Consem ncsel6Wure forworkeescompen- a/
wtion, r providedhhin(Pe by Ss issued.5700 of the War Code.for the pertoamence of we
wrote for which Ws permit is iuued.
❑1 hive and will mnmau Worker's Compensation Insurance,as acquired by Section
5700 of the IaWm Code,fm the performance of the wake for which this permit is issued.
My Wortee.Compensation Itwwna Cartier end Policy number re:
Cartier. Policy No.:
CERTIFICATE OF E)EMP ION FROM WORKERS' '
COMPENSATION INSURANCE
Crussuction need not hes compleen if the pefmit is for one hunewd dollars(SIM)
nr lea.)
1 amfy that In the performanet of the work for which Ni.permit is issued.I shall not
employ any person in my mutat se as in became subject to this Worli Compensation
Laws of Culifomia Dmi
Applicant
NOTICE TO APPLICANT.IL after making Ni.Certificate of Exemption.you should
beams subjm be Our Workees Compensation provinces of the Labor Code.you main
3Z forthwith comply with wish provinom or Nis permit shall W deem.d revoked.
z O CONSTRUCTION LENDING AGENCY
F 1herebyu111m thin Nen has cetulruc6nn leading agency for the performance of
fYi 1 the work fur which this permit B issued(Sec,5097,Civ.C.)
W Q Leanne.Name
jx Leader's Add.,
V Q i aNfy Nat I havt Ind this Applicant..and sok nut the aW W.information I.
D.!'! conecL I agme in comply with all city and county ordinances and suss Is..146.1 in
C) Wilding construction.and hereby autbmims repmenwiwa of this city to enter upon the
W shove-memioned properly far Impaction purposes.
6. (We)agree to ave,indemnify and keep harmko Iht City of Cupenino against
Iq Ilabilities,judgments,cmc ark expenses which may in my way amine Mafm Wit City �J
UF, in consequence of Ne gfanNng of this permit
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RCE REGULATIONS.
i{no — D
Re-roofs
"Pons,
V�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or town building occupant more or handle hazardous material
as dc0wd by the Cupertino Municipal Code,Chapter 9.11.ad the Health and Safety
Code,Section 155521.)?
❑Yes QI No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
I haakous air comuminanu as noticed by ftBay Area Air Quality Management all new materials for inspection.
an
❑Yes y!HNu
I hoe and the hnwdawmaterialsrcquirtmens under Chapter6.95 of the Califor-
n xHwlN&SafelyCode,Smiom 15505.25555 and 155th.I undewand Nati(Ne building
does not.mu ntly hew a tenant.Nu It is my responsibility in treaty the acap.,of me
requirements which must W met pdarwiuvxhaafa(!n kofocapaacy. ,. Signature of Applicant Date&-r zZn
owwr in aathofixedagent 'Date All roof coverings to be Class"B"or better