05050160 (2) CITY OF CUPERTIN0 "
BUILDING DIVISION PERMIT ' CONTRAC�TaRINF.ORMATIQN F,
Tn ;.zt�t>. x•i+R�e�3¢`"a§-ti" e`"-.. �say� ,ax.a° �'
BUILDING ADDRESS: PERMIT N0.
977 S TANTAU AV
7AIC'HITECT/EINGINEER:
ER's NAME: PERNUT ISSUE DATE
TSU KAI TSAI 03/27/2006
NE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONJob Descri tlGn
I hereby affirm that I am licensed under provisions of Chapter 9(commencing P Safion701ks)of Division3ofta Busitt. Profctiomco, mylicemfi REVISION--ADD 42 SQ. FT.
in full far¢and effect.
License Class Lie.g NO NEW PERMIT ISSUED/ORIG. 405020096
D" Contractor
ARCHITECTS DECLARATION EXPIRED-PD NEW PL CK FEES AND BAL OF OLD FEES
Ss I uMersunu d my plans shall be used public accords
U
6
s t; Liccnmd Prolcnsumal
g OWNER-BUILDER DECLARATION
iy 1 beach,hy affirm that 1 acscmpt from Me Contractors License Law for the
O O fallowing mason.(Section 7031.5.Business and Prof essim s Calc:Any city or county
e$ which requires a peen t to eomouct,Mail.impmw,demolish,or repair any noncore
L2i prior In its issuance:alsu requires the applicant for such Permit to files signed,uncmcat
s< Nat he is licensed pursuant to Ne provisions of the Commcmri License law(Chapter9 Sq.Ft.Floor Area Valua[ioR 115
ya,C (Cometningwith Sation7000)of Divinion3ofthe Bunircssand Professionscnde)or
Q that bcd exempts tM¢from and the buns for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Me applkanuo a civil Penalty of APN Number Occupancy Type
matarc Won five hundred doll.($500). P Y YP
❑I,as owner of Me Napanny,or my couldoye.with wag.Of Mair In compensation,
will do to work.and theswmute is nut intended or offered for sale(Sec.7W,Business
and Professions Code:The Conmctar's Lt..Law docs Out apply in an owner of Required Inspections
property w ho bui lds ar improv.there.,and who daeuuc h..,it himself.,Mrough his
ownver,M building or
pr such improvements witsam not inMMWa.ficfed far Me$choir.
however,Ne building or improwmenus old within Otte yeti ofimp o improve
f r Ne mater-
builder,will have burden of proving than a did not build or improve for purpose of
tile.).
.u corer to propcnY•am.d.ivdy conuacting with licensed mntnmors to \�
cauwct Ne jen(See.70aa,BZoimi and Proford.0a Cade:)The Conan.Li-
ccme law d not apply m an owner of Property who builds or improv.Marton,and
whocomm for such projects with a e.ntsactor(s)licensed pursuant in the Contractor's
Licence law.
❑lam cxemp nder see -.Bk PCf/°j�this /op
On.,Al Dak
ORK COMPENSATION DECLARATION
I
1 by affnm un r penalty of fiction,man of to following declarations:
❑1 have and will maintain aCenificam of Cament o self-imum fa WorkarYComMa.
sinka,se provided fa by Section 37M of the labor Code,for the perfo,muce of Ute
work for which this permit is ivad
❑1 have and will maintain Workers Compenution Insurance,as required by Section
3700 of the labor Cade,for Me performance of the work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Chis satire faced trot bewmpletcd if tie permit u foron,hund,eddoll.($100)
or Its.)
1 ccnify Mot in the performance of Me work for which this Permit Is Wood,I Malt not
employ any person in any man rte to me subject m to WmkeriC )euati
QLaws of Califamia.Dam
Applicant,
NOTICE TO APPLICANT: f,a r m ing this Car ifmaM of Excmptin,y shout
become subject to Me Wo is Com maria.provisions of to Loaf Code,you most
.J O foMwith comply with s Pravisio of Nis Permit shall be deemed invoked.
Z M CONSTRUCTION LENDING AGENCY
F I hereby affirm that them is a construction lending agency tot Me performance of
E
Me work for which Mis permit is word(Sec.3097,Civ.C.)
Tfl lender's Name
a z lender's Address
U Q 1 cenify Mat I have mad this application and sum that Me above information is
L, P^ coned.I agree to comply with all city and county ordinances and sur laws Misting o
0U building consuuction,and hereby auNonw representatives of this city to enter upon Me
�V) ahovcmcnsi.ncdpropcs andor epownis purposes.
(We)agree to sew,indemnify and keep harmless Me City of Cupertino against
F N Iia biliatjudgmc.,eats aneCAMISpeomit. may in anY way accts against utd City
U z inc.meganee of the granting CAMIS pcamil - �^ UL
APPLICANT UN ER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2-?�
-S4*
SOURCE U At S.
z O Re-roofs
Signmurc A lican onameour gM
AZARDOUS MATERIALS DISCLOSURE Type of Roof
ill the app cant w future building occupant store or handle hazardous mamriaf
u deft ed by the upenino Municipal Code.Chapter 9.12,ud Mo HcalM and safety
.Section 35533(0)? All roofs shall be inspected prior to any roofing material being installed.
❑Y. (�1�9 Na
Will the applicant or fuutture building acupam use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit Word.air cmustain cos as defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes rpNo
1 have mad Me huardous maerials requirements under Chapter 695 of to Califor-
nia Health&Safety Coda,Savav 25505,75533 and 25534.1 undcmand Mat if Mc building
does not cu ly M1aw a en Mat it u my responsibility o non y tM pant of Nc
myuirtmcn icn ant apt;.rnt;ss„naofacenia4c recap rY Signature of Applicant Date
Owner.,a the cage n L new All roof coverings to be Class"B"or better