05100192 (2) CITY OF CUPERTINO .*»� `
BUILDING DIVISION PERMIT dCONTRAGTQRINFORMAT-IO
BUILDING ADDRESS: PERMIT NO,05100192
18615 RALYA CT
OWNER'S NAME: PERMIT ISSUE DATE
QI LIN 12/13/2005
E; SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ' ELECT PLUMB MECH
0 0 0 0
Sop LICENSED CONTRACTOR'S DECLARATION JobDescri tion
MM1 seamy affirm that 1 am licensed under provisions of Chapter 9(commencing P
with Sudan 7000)ol'Dirbsion 3 dime BudrcasaM Professed]=Code.and my[am=Is
in full fora and sit= ADDITION 3161 -BEDROOM/EXTEND BATH AND
jz Liana classCao
Dam-
KITCHEN/RECONFIGURE OPENING AT HALLWAY 221
E Contractor
ARCHITECTS DECLARATION
1 understand my plena shall he used as public rtcnrm
3 Licensed Professianel
G 3
OWNER-BUILDER fa m Ce CombeON
Z I hcmhy.(Sere on 1 am esemfrom the Cuame,Ca Lions law for the
O C following mason.Permit
t 7031.0.Seamus,educt. and Pmfarium Cade:Any shy or county
$ whichitsIssuance.
ssamputees•permo re cores the a@c,hmprow,depermit
t,or repair any oUrml
a�n
prior=eta iauan pursuant
requires theappin of for achrucamS License
icenso file a al ned Law(Chapter
xxF-
ethe]he I,Iiwit pursuant rothe of Division
isiav of the Co nlmcmhnittnslaw,Coe)9 Sq.Ft. Floor Area VaIU 6x8957
tiro 'hammencingwWhection refrom 00)and
basis n3 of allegehe d
cumptim,(Any vi Cade)of
a� That he h see=p]Therefrom and die basis for Ne alleged exempNan.Any violation of
Section 7031.5 by any applicant fora permit objects the applicant m a civil penally of APN Number Occupancy Type
not mom thea Bw hundred doll.(5500). 37525004 . 00
0 1,as awnu of the property,army employers wide wages as deo mm carper adon,
will do dee work,and thesbumurt is net intended areacted far sale(Sm. Business,BusinRequired Inspections
sed Proramioln Code:The Comm=onm e
License law does ant apply an owner or 9 P
property who hu0ds or Improvestheroon,and who does such work himself err through h0
awn employees.provided thatsuch impromements am not Intended morteed for ale.If,
however,dee building or improvement is mid within ane year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
tile,).
❑1.as owrcr of the prepare,sm excludvsly conuasing with liaved conuacron m
construct dee project(Sec.7044.Business and Professions Code:)The Conmacmh U.
cerate Law does not apply as an awnes of propeny.who builds or improve thereon.and.
who comment for Bush projecu with acomracmr(s)licensed pursuant to dee Con amuses
Lke•..law.
❑lam"ma un/rye Dec. Bk PCfm Ice mason
\X IZ I
Owner A i 1 Dste
WORK�COMPEN A DECLARATION
1 hereby affims under penally of perjury arc of the following decimations:
1WnaMMllmaineinaCWOcamof Coventmalf-alumfar Wo ,C=Mn-
ta0on,as provided for by Sad.3700 of the Inbar Code,fm the performance of the
work far which this permit IB Iooed.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Calc,for the performance of the wank for which this p ornh is booed.
My Workers Compensation Increase canner and Polley number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the perms is foranchundred dollar(SIM)
or lea.)
I mnify that in the performance of the work for which this Permit is issued.I shall not
employ any person in any manucrmssm eco= Ibjmto TxWorkeracompensnion
Laws of California.Da
Applteant
NOTICE TO APPLICANtIf. making ittlisCcitifkasm of Exemption,you should
become abject to the Worker's Compensation provisions of the labor Code.you muss
.,O mr0ovor comply with such provisions or Nis permit&hall he domed rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is construction lending agency for the performance of
Ci the work for which this permit Is Issued(Sec.3097,Civ.C.)
Landers Name
O z Landers Addrtas
U0 1 certify that I ban and this application and Bus that the show information is
14 contracts.l agree m comply with all city and county ordinances;and more laws relating m
0 building construction,and hereby amhoda representatives of this city to enter upon the
[5l show-inerfovd property for Inspection purposes.
y (We)ISme to uve,indemnify and keep harmless the City of Cupertino against
rat liabilities,judgmcns,costa and expenses which may In any way see=against said City
U 7 In consequence of the gaining of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date otr—
SOURCE REGyLyTION . _
ley -14 /' I�� L�1 Re-roofs
Signature of Appli=VCamema — Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or fumro building occupant nom or handle husrdov material
a defined by the Cupertino Municipal Cade.Chapter 9.11.am;the Health and Safety
Coda,Section 15531(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yca 0 N
Will the applicant or future building occupenl um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havacdoos air antamimenta so de0nod by dee Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes ON.
I have mW the haaNtm&materials requlmmenut under Chapter 6.95ortheCalifot-
.is HUI"Safety Code,Smile.25505.25533 ma 25534.1 understand that if the building
dues rat curcnit h w•tenmk Nat it h my rcspovlhillly m notify the=upant of the
mquimmcnls wni m IkC mm �m�a=once ora CcniRnma(G�cur Signature of Applicant Date
Owner or authod'2.c' t I Dam All roof coverings to be Class"B" or better Ci