03020093 (2)CITY OF CUPERTINO
77,1_ ^ �� `` '
COO NTJUA-tOR �INFORMATJON:
BUILDING ntvlsloN .PERMIT
.. .: ....,i?sa.
BUILDING ADDRESS:
PERMIT NO03020093
R'S NAME:
PERMIT MUE DATE
SHONG WANG
.HONE:
SANITARY N0. CONTROL NO.
ARCHITECTIENCINEER:
,BUILDING PERMIT INFO
`
BLDG ELECT PLUMB MF.CH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
o
1 hereby affirm that I am licensed under previsions of Chapter (commencing
with Section 7") of Division 3 of the Business and Professions Cc&, and my license is
in effect,
SFDWL—LIVING SPACE 3,611-
Licenlse Classnd
Lic.k
Dam CoMmemr
GARAGE 498
SQ FT. ppp��� ■■■ ■
E
ARCHITECTS DECLARATION
DrecordsECLARATION
1 understand my Plans shall recd as public
F I NA■ E
■■FYI
Licensed Professional
OWNER BUILDER DECLARATION
License Law (or
1 hereby affirm that I am exempt from the Contractors the
following reason. (Section 703 I.S. Business and Professions Code: Any city nr county
NOV �`1� 2004
which requires a permit m construct, eller. improve, demntist.'or onto, any stomion
poor to its issuance, also rcyu res the applicant for such Permit m file a signed statement
he is licensed 0 the the Contractor's License Lbw (Chapter 9
Sq. Ft. Floor Area
tion
that pursuant previsions of
(commencing with Section 7000) of Division 3 of the Busincss and Professions Code) or
10900
Net he is exempt thcmfrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 9031.5 by any applicant (of a permit subjects the applicant to a civil Penalty of
not more Nan lout hundred delta. (55007.
37508018.00
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will du the work, and the Structure is oat intended oroffered for sale (Sec. 7046, Business
and Professions Cade: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himselfor through his
own employees, provided that Hoerr improvements are not intended or offered for able. If.
101 —
FOUNDATION
however, Ne building or improvement is sold within one year ofcompletion.due owner -
builder will have Ne burden of proving that he did not Wild or improve for purpose of
102 -
PIERS
Sale')'
103 -
UFER
®,1, as owner of the property, am exclusively contracting with licensed contractors to
10 4
REBAR
construct the project (Si 7044, Business and Professions Code:) The Contractor's Li
-
emote law does not apply m an owner of property who builds or improves thereon. and
105 —
ANCHOR BOLTS
who contracts for such projects with a contractors) licensed pursuant o tint Certainties
License
106 -
SEWER & WATER
❑ l tmexempl undo Sec. B& P C for this Mason
202 -
UNDERFLOOR PLUMBING
r O Da 6a-/ -03
203 -
UNDERFLOOR MECHANICAL
WO ER COMPENSATION DECLARAT N
t - - I hereby affum under penalty of perjury one of the following declarations:
204 —
UNDERFLOOR FRAME
❑ I have and will maintain a Cenificate ofConsenuoscIr-loud mrworkers Compcn,
205 —
UNDERFLOOR INSULATION
Union, as provided for by Section 3700 of the labor Code, for the performance of the
301 -
ROUGH PLUMBING
work Nr which dua pe.it is issued.
302 -
TUB & OR SHOWER
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 oflhc labor Code, for the Performance of the work for which this permit is issued.
303 —
ROUGH MECHANICAL
My Worker's Compensation Insurance carrier and Policy number am:
304 —
ROUGH ELECTRICAL
Carrier: Policy Ni
305 -
FRAME
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
306 -
HOLDOWNS
(Tbissectinn need not be completed if Permit is for one hundred dollars(SIM)
307 —
INSULATION
Irmo.)
308 -
SHEETROCK
employ certify ny err the n any manners the work for which Nis permit is issued, I ahall nut
309 —
EXTERIOR LATH
Lawso California.oninanymanncrsnasml,ecomesabjectmmeworkers'cnmpcnsation
LawsofcarroD°"
Applicant
310 -
311 -
INTERIOR LATH
SCRATCH COAT
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Forthwith comply with Rich provisions to this perm i t shat l be deemed raveled.
313 —
ROOF NAIL
CONSTRUCTION LENDING AGENCY
501 -
FINAL ELECTRICAL ENERGY
I hereby cabin that there is a construction lending agency l'nr the performance of
502 -
FINAL PLUMBING ENERGY
Fee work fur which this permit is issued (Sec. 3097, Civ. C.)
UnderaName
503 -
504 -
FINAL MECHANICAL ENERGY
FINAL BUILDING ENERGY
Undera Address
I certify that I have read this application and state that the above information is
505 -
FINAL ELECTRICAL
correct. I agree to comply with all city and county ordinances and state laws relating m
building construction. and hereby authorise represcnutives of this city M enter upon the
GAS EST
abovomentioned property for irupection purposes.
07
FI
WS) agree to arc, indemnify and keep harmless the City of Cupertino against
Iiabililinjudgments, costs and expenses which may in any way accrue against said City
5
ICAL
in Consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:5
Date
SOURCE REGULATIO_P/
biU
5 4 -
INAL
INAL PUBLIC WORKS
1 �� 463Re-roofs
Sr urn Appbcan onuactor em
HAZARDOUS MATERIALS DISCLOSURE
Type Of RN -
ROOF PLYWOOD NAIL
Will the applicant or future building occupant store or handle haaardous material
defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
603 -
ROOF BATTENS
.semea 25532(an
All roofs sb4lgbe insNgtq#ri?Ntojap
being installed.
❑Yes {{ No
g�Flg Elaterial
If a roof is installed without first obtaining an inspection, I agree to remove
Wits the applicant or future building Occupant use equipment or devices which
emit havaedous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑Yes ®Nu
I have mad the ha anlnus materials Myuimments under Chapter 695.f the Cali for
nit Health & Safety CUM , Sections 25505.25533 and 25534.1 understand that iftlee building
does not currently have a tenant, that it is my responsibility to and I the w:cupant of the
rcyuiM hick mntpdnmisaoanceofaCcrufwa OccuPaney.
Signature of Applicant Date
�(�
All roof coverings to be Class "B" or better
O
r lir authorized agent Dam