07070134 CITY OF CUPERTINO
BtiiLD1NG DIVISION PERMIT € R
BUILDING ADDRESS: PERMIT NO.
21733 ALCAZAR AVE CH BUILD, INC 07070134
OWNER'S NAME: PERMIT ISSUE DATE
DAVID & RIE WONG 665 3RD :;T STE 541 07/17/2007
NE: SANITARY NO. CONTROL NO.
(415) 344:-0830
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O`p LICENSED CONTRACTOR'S DECLARATION
U(= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
:Z uj with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMP POW.�R POLE.
=n in full force and effect
i License Class Lic.8
:—a Date Contractor
„a ARCHITECTS DECLARATION
C4 V I understand my plans shall be used as public records
,a
O N Licensed Professional
h} OWNER-BUILDER DECLARATION
j a I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
% 9 which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior 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 S a.Ft. Floor Area Valuation
i- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $900
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 Occu anC T e
not mom than eve hundred dollars(M). 35719019 .W p y yp
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: e The Contractor's License Law does not apply to 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 offend 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.).
X1,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 Caw 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 Contractor's
License Law.
0 I am exempt u r Sec. / B&P,CC for this tenon
Owner ( �� Date
�•7 R ER'S^MPFN91 TION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
'n 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.
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 arc:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($10a)
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 manors,I�sm ct to the Workers'Compensation
Laws of California. a,
Applicant _
NOTICE TO A C W.11Wr makiq}(ihis Certificate of Exemption,you should
become subject to the Workesli Compensation provisions of the Labor Code,you must
.7 O forthwith comply with such provisions or this permit shall be deemed revoked.
n-+
CONSTRUCTION LENDING AGENCY
rA
E-+1-+ I hereby affirm that there is a construction lending agency for the performance of
ft> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Names
az Lenders Address
U 0 1 certify that I have read this application and state that the above information is
L>, 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
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r/I liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
r" APPLICA UNDERSTANDS AND WILL'COMPLY WITH ALL NON-POINT Issued b Date �-
SOURCE, ULATI S. /� �`! _
��// Re-roof:
Signature of Applicant/C actor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle h— ous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yes All roof 3 shall be inspected prior to any roofing material being installed.
�Io
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?
0 YesNo
I have mad the hazardous materials requirements underChapicr 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that.ifthe building
does not currc ly have a tcnanL,that it is my responsibility to notify the occupant of the
requiremcn ynetp�or�cf a Ccrtific c of Occupancy. Signatu-e of Applicant Date
(CCCCC//11//' �7"0 All roof coverings to be Class"B"or better
Owner or amhori-z-ed anent Date