07010169 777
CITE'OF CUPERTINO
BUILDING DIVISION PERMIT ( RM�ITIQN�
PERMIT NO.
BUILDING ADDRESS:
21267 STEVENS CREEK BLVD #320 TBD - 70 BE DETERMINED 07010169
PERMIT ISSUE DATE
OWNER'S NAME:
THONGTOR SUK 02/15/2007
SANITARY NO. CONTROL NO.
,NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
a 0 a a
p p LICENSED CONTRACTOR'S DECLARATION Job Description
VI hereby affirm that I am licensed under provisions of Chapter 9(commencing
z U, with Section 70(X))otDivision 3 of the Business and Professions Code,and my license is REVI S I C N-REVISE MECHANICAL/HOOD PLANS JP
a a infull force and eft
; z LleerueG7 ci!6 Lic•>t CONSTRUCTION PD FOR BL 1/22/07-MECHANICAL
;5° Date CHITEc SD contractor -EQUIPMENT SHALL NOT BE VISIBLE FROM PLUBLIC RIGHT
i C4< I understand my plans shall be used as public records
)yU
U.y Licensed Professional
O< OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to constructalter,improve,demolish,or repair any structure
Z r
priorto its issuance,also requires the applicant for such permit to frac a signed statement Ft. Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. 0
21--•C (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
u that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars($500). 3 2 6 2 7 0.:5 . V U
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dols not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed.pursuanl to the Contractor's
License Law.
❑I am exempt under See. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DEC LARA ION
I hereby affirm under penalty of perjury one of the following declarations:
Q I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Cy'l have and will maintain Workers Compensation Insurance,as required by Section
00 of the Labor Code,for the performance of the work for which this permit is issued.
My Worke ompenution Insurance carrier and Policy number arc:
Chu Policy No.:
CERTIFICATE OF EXEMPTION FROMWORKERS*
COMPENSATION INSURANCE
Chis section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
a+> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Lender's Address
U C) I certify that I have read this application and state that the above information is
w correct.1 agree to comply with all city and county ordinances and state laws relating to
O U building construction.and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequc 21C.0 the granting of this permit. Date
APPLICA UNDE TAN AND WILL COMPLY WITH ALL ON-POINT Issued by: Z
SOURCE EGULA N . t
IS S c L Re-roof::
o pp1ican&Contractor I Date Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mzz
I Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof 3 shall be inspected prior to any roofing material being installed.
❑Ya
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not urrenlly have a tenant,that it is my responsibility to notify the occupant of the
requirenit which ust t pri issuance of a Certificate of Occup ey. Signatul a of Applicant Date
All roof coverings to be Class"B"or better
r a orired agent Datc