07060100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDNG ADDRESS:
1711 ALCAZAR AVE TBD - TO BE DETERMINED 07060100
PERMIT ISSUE DATE
� XS NAME:
HSING KUNG & MARGARET KUNG 7
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
0 0
C Z LICENSED CONTRACTOR'S DECLARATION
vC I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z(�� with Section 7000)of Division 3 of the Business and Professions Code.and my license is HOUSE DEMO
y in full force and effect.
v2 Z License Class Lam•
t-p Date Contractor
I -a ARCHITECTS DECLARATION
i a< 1 understand my pians shall be used as public records
i4V
n.ti Licensed Professional
C a OWNER-BUILDER DECLARATION
t} t
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
co following reason.(Scotian 703 1.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
r H prior w its issuance,also requires the applicant for such permit to file a signed stateroenl Valuation
Z, Ft.Floor Area
that he is licensed pursuant to the provisions of tiro Contrxtur s License Law(Chapter 9 q• $10000
t=-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number
not more than five hundred dollars($500). 3 tJ 7 19 0 7 S (
0 1,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 sal (Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an own"of
property who builds or improves thereon,and who does such work himself or thmngb 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
saki.).
1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The ContratxOes Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractors)licensed pursuant to the Coauactofa
License Law.
am exempt under Sec. B&P C for M
.r Date
WORKER'S COMPENSATION DECLARATION
I here affirm under penalty of perjury one of the following declarations:
❑I have a •II maintain a Certificate of Consent to self-insure for Workees 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION 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 shag oat
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APP A r making this Ccnifcate of Exempilitm,YOU should
become subject to/he Worker's Compensation provisions of the Labor Code,you must
Z forthwith eompl ith such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a concoction lending agency for the performance of
�G> the work for which this permit is issued(Sec.3097,Civ.C.)
W M Lender's Name
z Lender's Address
U C) I certify that I have read this application and state that the above information is
LL .. correct.I agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(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
f,) Z in consequence of the granting of this permit. Date
�+ APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NO POINT Issued by:
SOURCE RE TIONS. 6/
b Re-roofs `
Signatur f Applicant/Contractor te T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
.find by the Cupertin7N.
'pal Code,Chapter 9.12,and the Health and Safety
a,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
0 Yes
Will the applicant or future building occupant use equipment or devices which
If a roof i;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as dcfncd by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes IN.
I have read the hazardous materials requirements underChapter6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant} at it is my responsibility to notify the occupant of the
requirements hich must be me 'orto' t,ancc Cerif aracupaney. Signature of Applicant Date
All roof coverings to be Class"B or better
Owner r orizcd agent Date -'—'---