03060121 (2) F„ '
TY OF CUPEWHISOBUILDING DIVISION PERMIT x�CONTRACTOR INFQRMXT NLgINGADDRESS: K & M DEVELOPMENT INC PERMITN003060121
FRS NAME: 1060 WEST HILL CT PER.Mrr ISSUEDATE
CHI PING YANG 2003
ONE: (408) 253-9787 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
±o 0 LICENSED CONTRACTORS DECLARATION lob Description
Iu u I hereby affirm that 1 am Iimn¢d under provisions of Chapter 9(commencing p
w wish Section] poi DivisionJof Nc Businw and Pr{�fcssinm Codc, din,ict....
a in mu mm. « ,/ �s DEMO
j z Liccn a c� Lic.s I�Ia�
p Dam C.moeor - i C'_
34 ARCHITECTSDECLAR ON
W U 1 senders nd my plans shall M used as public records
t, Licensed Professional -
g OWNER-BUILDER DECLARATION
a Y 1 hereby affirm that 1 um exempt from the Contractor's License Law for the
❑O following mourn.(Section 703 1.5.Business and Professions Code:Any oily or county
<m u�< which requires a Permit to emstrucl,alma improve,demolixh,or repair any structure 0 prier to its issuance,also requires the applicant forsuch pCmlit to file a slgnedauncllmat
^x that he is licensed pursuant in the previsions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area ,Valuation
2 (commencing with Section 7”)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and to basis for Ne alleged exemption.Any violation of 34216034 . 00
Section 7031.5 by any applicant fon permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mart than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compcnsstion,
will do the work.and the structure is not intended or offered for sale(Sec.7041,Business 7 04 DEMO-
Add Professions Code:The Cmurac o'.License law dons not apply to an owner of Required Inspections
property who builds or improves thereon,and whodoessueh work himaelror through his
own employees,provided that such improwmcmu are not intended or offered for sale.If.
however,the building or improvement is said within One seat Of compleian,the owncr-
builder will have On burden of proving that he did not build or Imprint for purpose of
sal..).
0 1,as Owner of the propcny,am exclusively contracting with Iiccnsed oonmeors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- _ \
cave law docs not apply to an owner of property who Wilds or improves thereon,and, <
who contracts borsch projects with a comraeor(s)licensed pursuant in the Comment's (�
License law.
❑ 1 am exempt ands,Sec. B k P C for this reason _ e
Or Dam \ /�
WORKER'S COMPENSATION DECLARATION v
I hereby affirm under penalty of perjury ore of the fallowing dealsotions:
1 have and will maintain a Certificate of Consent to sel6insure for Worker's Compen-
sadion,As provided for by Senior 37Mof the Leber Code,for the peRonnancc of the
work for which ths permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,az required by Section
37M of thc labor Code,for the Performance or the work far which this permit is issued.
My WMW Compensation Insurance carrier and Policy number rg Z
C ✓ �. Policy N015 i7�_
CPP17 AN WORKERS'
MPENSAT10N INSURANCE
(This section need nootJt W completed If the Permit is for one hundred dollars($HIO)
M less)
I cenify Nal in the perfmmancc Oldie work far which this permit is issued.l shall net
employ any person in any manner An As to become subjecno the Workers'Compensation
Laws of C.Hrood..Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you sMuW
Westin subject 10 the Worker's Compensation provisions of the UMr Calc you must
.,O fonhwidh comply with such provisions or this Permit shall M deemed remind.
z '-' CONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a constmclina lending agency l or the Performance of
!Yi a7Ne work(a,which this permit is issued(Sao.)(197,Civ.C.) '
CQ Under's Name
Z Under's Address
V O 1 mnify that I have read this application and stale thu Ne eMv.information is
Fcorrect.I agree to comply with all city and county ordinances and surd laws relating 10
U building consmOction,and herebyauthocirs represemativa of this city to enter upon the
W
above-mcntioned property for ivpcction purposes.
gra (We)agree m save,indemnify and keep harmless the City of Cupertino against
rn IiabillhaSjudgmenls,costs and eapensv which may in any way accrue againslsaid City
U Z Aconsequence Of the granting Or this Permit.
LICANT UNDERSTANDS AND COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R LATIONS.
2 '}OURe-roofs
S anocanmeOU m
HA S MATERIALS DISCLOSURE Type of Roof
the app mart or(Mune bulling Occupantrare or handle �aua material
def, eO by the Cupertino Municipal Code.Chapter 9.13,and IM Health end Safely '
Section 25532(.)? a��a�/// All roofs shall be inspected prior to any roofing material being installed.
�Ycs
Will the applicant or fuwrere hnmmng accapand use equipment or devices womb If a roof is installed without first obtaining an inspection, I agree to remove
it hmardnus air contaminants defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes u
I have mad the haoNuus materials requirements under Chapterii.95 often,Califon
nia Hadco&SafetyCode,Sections 75505.25533 and 25534,1 understand that ifdc building
does not currently hoc a Iron that it is my responsibility Inokfy dr.y�occupantthe
oT
mnu pdrome which he ren prior to issuance Ora Outifica of O'er 3 Signature of Applicant Date
wneranath %e All roof coverings to be Class "B"Or better
M ?Tr