04030001 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ONT IFU:RM.t�'CU1�T�"r"
BUILDING ADDRESS: WAN LI a CHEN PERMIT NO.04030001
ERSNAME: PERMIT ISSUE DATE
WAN LI C14RN
'vNE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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+�O'z LICENSED CONTRACTOR'S DECLARATION lob Description
U I hemby affirm that 1 am licensed antler visions of Chapur 9(commencing
with Section] )ef Division 3 of the Bus in dProfruinnr,Code,an mylicenscia _
Sg� ucema`'wCYy� Lk.N �RTEVISION- SKY LIGNTS
ppp Dao coma L O—NEW._$ MIT ISSUED/ORIG. #04020162
NJ
"1 A HITELTS DEC ON
31 1 undcnund my plans Shall he used a r¢ords
6
it: Professional
p
OWNER-BUILDER DECLARATION
d 0 0 I hereby a(0m oOat 1 1. exempt from the Conine Co e:Any c Law for the
p rO! following moron.(Steuart 7031.3,B.ithe,s sed are.de Professions Cour:Any city or county
iy!$LL poor 1 mgJsciees apresto I.requires
e4alcor,Impmsuh Perlin firepair edtWCWR
Fly pears its tensed ,alSorequithe beapplicantfar such permits filen Law(suumem
C
that
egseu pursuant to the of DivisionfNthe Buumand Professions;
Code)or Sq.Ft.Floor Area Valuation CO
re�$ th(commencingasisxempth Section 70nd but&oforn 3 O the B ed exempt on.My solation of YY
that he Is exempt therefrom and the bale far use alleged Gumption.My violation of
Section 7031.5 by any applicant for a permit Subjects the applicant in a civil penally of - APN Number Occupancy Type
not mom than live hundred dollars(5500).
❑I,as owner critic property,a my employees with wages as their sole compensation, 36203030 , 00
will do dte work and the structure is not intended nr oflemd fens.Sec.7W.Business
and Professions Code:The Com tech n's License Lew does not apply to an owner of Required Inspections
property who but lds or im proves thereon.and who does such work himulf or through his
own employees,provided Nmauch improvements an,maintained oroRered forsale.IL
however.the building or improvement is Sold within one year of completion.the owner- C
builder will have the burden of proving that he did not build or improve for purpose of \
sale.). (w
0 1,as owner of the property,am exclusively contracting with licensed contractors toV lw
construct the pmjen Communist's(See.7W.Business and Professors Code:)The Communist's LI- \ V
arae Law docs not apply to an owns of property who builds or improv themes, it
who contracts for such projects with a commicsr(s)lioenud pun e m to the Contractor's
License law,
❑I am exempt under Sec .B k P C for this meson
Dau
WORKERS COMPENSATION DEC ATION
I hereby elfmn under penalty of perjury ane of owing declandom:
1 have end will mainWn a Cenifcoteof Conant to ulf-inaum for WorkeesCompcn-
satton,as provided for by Section 37W of Ne Labor Code,for the performance of to
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insunn c,as inquired by Secure
3700 of the Labor Code,for the performance of the work forwhich this permits issued.
My Workers Compensation Insurance easier and Policy number arc:
Censer. Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu semlon need not M completed time Permit Is forms,hundroddollars($100)
or ass)
I certify that in the performance of the work for which this permit is issued,I shall net
employ any Nixon in any manner an as in becomesubject to the Workers'Compensation
Laws of Califcroia.Dau
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of me Labor Code,you must
.J O forthwith comply with such provisians or this permit shall be deemed invoked.
„Z,i ^' CONSTRUCTION LENDING AGENCY
[-. ► I hereby aRum that there is a construction lending agency fnr NC Performance of
!Yi > the work for which this permit is issued(Sec.3097,Co,C.)
W A Undoes Name
Z Lender's Address
L)Q I certify that 1 have mad this appliesuon and suss that the about information is '
fl,U correct.1 agree to comply with all city and county ordinances and suite laws minting to
C) building construction,and hereby autharix mprcunutiven of this city in enter upon the
W above-mcntimod property for itupection purposes
LL (We)ague to save,indemnify and keep harmless the City of Cupertino against r
,I limilides.judgments,cosu and expenses which may in any way acerae against Said City
U F7in 7
APPLICANT or to licensing of I
TUNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT Issued by: Da /
SOURCE REGULATIONS.
Re-roofs
Si source(Mpfi uCanmctor au
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oecupant sere or handle havardous material
Med by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
e,sretiezss3z(a)7
❑Yes `,No All roofs shall be inspected prior to any roofing material being installed.
ACI
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
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
DI...iel7
Yes
I have mail the hsaa a .moials mquiinmen;under Chapter 6.95 of the Califon
me Health A Safety Code,Secumu 25505.25533 anti 25534.1 undeuund Nu ifthe Wilding
dins not cumntly have a unset.that itis my reSpot body to noddy the Occupant of the
rcyui mcntsw ch must be melpsa toissuanceefa uo[ u ry. Signature of Applicant Date
O
Owner or ashenxd agent Dam All roof coverings to be Class"B"or better