04030226 (2) CITY OF CUPERTINO
BUILDING DIVISION - PERMIT CONTRACTOR INI''URMATION
BUILDING ADDRESS: PERMIT N00 4�0 3 022 6
682 S
v
ER'S NAME: PERMIT ISSUE DAM /
QUEENIE FUNG BUBBLE
E: SANITARY NO. CONTROL NO.
ARCHITEC YENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
glop LICENSED CONTRACTOR'S DECLARATION
gI hereby affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description
a>j with Section 70110)of Okvlsion Sof Ne Basin s d Prossio
fens Code,mdmylimnseis
$'z
< fo and if Z TI--BUBBLE TEA ZONE
D� ate..e u
DamAcxlTEcrs D Cont actor N CONTRACTOR: KEN LEUNGVNIALE
�i 1 undcnunJ my plans dull M reed uyuh rceards
U
Gt; Licensed Professional
OWNER-BUILDER DECLARATION
2 I hereby v0irm that I am exempt from the Contractor's License Law for the 0Profession
O 2004�
O fallowing mason.(Section 7031.5,Business and Profuns sioCode:Any city or county
2 ff which requires a permit to construct,alter,improve.demolish,lir repair my structum
prior m its issuance,ileus requires do,mpkicam lydw,h Permit t.fleeaignedsummem
pp <
that he is licensed pu..or to that provision.!Ne Conlnutefs Limn.Law(Chapter 9 Sq. Ft. Floor Area V I 000
v? $ (commencing with Section 7000)mf Oivision 3 ofthe Businessand Profession Code)to
Nal he Is exempt thetefrem and the buss fax Ne alleged exemption.Any vuhnne.or
Secdon 7031.5 by any applicantfora purnh.bjecu the applicant to a civil penalty of ppN Number ecu arc e
No more than five hundred dollars(S500).
35717012 . 00
PNum P y Typ
❑I,u owner.!de Propmy,w my empl.yen with wegrs u their.le cmnpensatlon,
will do the wank end Ne."cuor b mol Intended oroQered rte sale(Sec.7014,Business
and Professions Code:The Contractors License law dues not apply m an owner of Required Inspections
prepeny who builds or improv Hereon.a nd who does each work hlm.l f or thm ugh his
own employees,provided Net seep impmwmenLL K not intended oroRered fmsale.If.
however,Ne building or imp.vem"l la sold within..you of completion.the mvoery
builder will have hire burden of proving that he did non build or improve for purpose of
Ask.).
❑1.as owner of the propeny,am"elusively contracting with licensed conations to
construct the project(Sec.70".Business and Profusions Code:)The Conuae.rs Li•
mase law dors not apply at an owmar of property who builds or Improv demon.and
who con cion for such projects with aconuumr(s)Hamad pursuant m the Contractor's
License Law.
1 And exempt antler Sea ,B&P C for this moon
Dam
WORKERS COMPENSATION DECLARATION
1 hereby aRmn under penalty of perjury ane of Ne following decimations:
I have and will for by
a CertificateM of Consent I. for
a performance
aCompcm
cation,r provided Pe by S.tion 3700 of the Ubor Code.for the peRonnana of the
work for which this permit u tossed
❑I have and will maintain Worker's Compensation Insurance,u required by Section
37M of doe Ulm Cada,for Ne-p If in of Ne wo for which Nispermit is issued.
Y Wmkera Cranium Non ensu dd ri'er and P number are:
CE IFICATE OF EKEMPnON FROMWORKERS'
COMPENSATION INSURANCE
(NHsutlon need not becomplcmd ifthe p.est,Is foram,hundred dolts(SI011)
or less.)
T sentry that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner an As to bmume.bject m the Workcn'Compensation
Uwe of California.Data
Applicant
NOTICE TO APPUCAKr.If,atter making this Ccnifmate of Exemption,you should
become Subject in the Worker's Compeasation previsions of the Ube CMC you most
.J O forthwith comply with such provision or NMM
is Permit all deemed revoked.
z., CONSTRUCTION LENDING AGENCY
Ihertby allirm
that Nem Iu.onstructinn lending agency for Na ped.....of
6i the work for which Nu permit is iumd(Sm.3091,Civ.C.)
GELenders Nam.
D
Z fender's Address
U Q I certify that I have read this application and sue that the about information is
Is.!' correct 1 qnn to comply with all city and county ordinances and sok laws meaning to
C) building construction.and hereby authorire rcprC.nodv of No city to enter upon the
457 above-mentioned pmpeny for impaction purposes.
gy (We)agree 1....indemnify and keep harmless the City of Cupertino Against
rn liabilities,judgmcno,costs expenses which may In any way memo against aid City
(„) in consequcnee a( syn i !this permit.
APPLICANT DERS S AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOU CER LATIO
Re-roofs
Sign rc.f p mramr a
HAZARDOISM IALSDISCLOSURE Type of Roof
Willdeapplicentorfutumho' ngom.pa rs...,haMlchuudousnded.)
dcftned by the Cupertino Municipal Code,Chapter 9.17,and the Hcallh and Safety
c,Sc Non 25532(a)? All roofs shall be inspected prior to an roofing material beim installed.
❑Yea No All P P Y g g
Will the applicant or future building occupant use equipments devices which -If a roof is installed without first obtaining an inspection,I agree to remove
n huardnu air conominanu u defined by the Bay Arca Air Quality Management all new materials for inspection.
Disuicl'
❑Yes INu
I howney theh®a us materials requirements under Chapter 6.95 of the Califon
no H.INe:Salttyco4 ' .25505.25533 ad25531.IunMnstM lhaziflM Wilding
dao not rtAS0,haw• t that it u my respomihility m notify the occupant of the
reyuire c ih¢hm . ctprior miuuag .racenin"teerQpap ey. Signature of Applicant Date
Owner. a.tMrim ascml Date All roof coverings to be Class "Bt'or better