07050025 CITY OF CU
PE
RTINO
DIVISION
PERMIT
BUILDING <:.;.:....._,,:. .... . .
- �
BUILDING ADDRESS: PERMIT NO.
21733 ALCAZAR AVE TBD TO BE DETERMINED 07050025
^R'S NAME: PERMIT ISSUE DATE
)AVID & RIE WONG 12/04/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
q p p LICENSED CONTRACTOR'S DECLARATION - Job Description
w I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z t with Section 70110)of Division 3 of the Business and Professions Code,and my license is S FDWL—.!5 4 4 ' /GARAGE 4 6 2 ' PERMIT
a in full force and cffecL
License Class Lie.B APPLICATION EXTENDED MAX 6 MOS TILL 5/03/08 .
p Dat- Contractor
Lu ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
Oy Licensed Professional
n OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
a O following mason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
y Zprior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
%t•- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $900000
y 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 e� Number I Occupancy Type
not more than five hundred dollars($500). 3 5 7 19 019:'l7
0 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 does not apply m an owner of q P
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.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themon.and.
who contracts for such projects with a contractor(s)licensed pursuant to the contractor's
License Law.
01.exemp nder Sec/J B&P C for this mason
r `/ �� Date/Z-1"67
WORK'ER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This 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.I shall not
employ any person in any m so as to become subject to the Workers'Compensation
Laws of California.Date
Applirant -/
NOTICE TO APPLICA :If,alter Making thistertificatc of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z"' CONSTRUCTION LENDING AGENCY
H►�— I hereby affirm that them is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.Q
W Q Lender's Name
Z L.cndees Address
U 0 1 certify that I have mad this application and state that the above information is
V." cormcL I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save.indemnify and keep harmless the City of Cupertino against
►F-r Liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
�. APPLICA WULA RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ✓'� _3`n
SOUR ONAn Q /
4/ !Z—f -0 7 Re-roofs
Signature ofApplicart ontractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of hoof
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes gNo
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
0Yes kNo
1 have mad 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
does not curre have a tenant that it is my responsibility W notify the occupant of the
requireme ch must be m ar to� uance of a Certificate of Occupancy. Signature:Of Applicant Date
._V� - ` / /Z—If''07 All roof coverings to be Class"B"or better
Owner or authorized agent Date