07010014 CITY OF CUPERTINO
13UILDAG DIVISION PERMIT C$)k�'��WCTO N-1 F. }��I.i4TIfIN
PERMIT NO.
BUILDING ADDRESS:
A
OWNER'S NAME:
CHUAN WANG & CINDY SHEN 1020 RUFF DR 01/03/2007
SANITARY NO. CONTROL NO.
ZONE:
(408) 377-9990
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
e U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=Zwith Section 7000)of Division 3 of the Business and Professions Code,and my license is INSTALLING CLEAN—OUT AND BACKFLOW PREVENTION
j n Z License Cfe and effec -_L L Lie.o DEVICE W FOUNDATION
3 t„p Datc o Contractor
t-]r ARCHITECT'S DECLARATION
LU U I understand my plans shall be used as public records
a
4 O H Licensed Professional
n OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
i 0 O following reason.(Section 7031.5,Business and Professions Code:Any city or county
<m which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement $ Ft.Floor Area Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $1550
nt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of c�}D Number Occupancy Type
not more than five hundred dollars($500). 34214042 V
❑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 oroffered forsale(Sec.70",Business Required Inspections
and Professions Code:The Contractor's License Law dors 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 Contractor's 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 pursuant to the Contractors
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- EF
sation,as provided for by Section 3700 of the Labor Code,for the performance of the [ i
work for which this permit is issued.
�t
❑I have and will maintain Worker's Compensation Insurance,as required by Section , Li
3700 of the Labor Code,for the performance of the work for which this permit is issued. ;
My Workee�s JCompensation Insurance carrier and Polity number are: iv
Carriers;� �f Policy No-* r� -1 -C'77
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 ceni( that in the performance of the work for which this permit is issued,I shall not F&OD employ any person in any manner so as to become subject to the WorkeriCompensationLaws 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.
Z CONSTRUCTION LENDING AGENCY
Qn 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
0Z
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
building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
rE y liabilities,judgmcnts,costs and expenses which may in any way accrue against said City -7
U Z in consequence of the granting of this permit. Date f
r--r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:qf��Ca
s ULATIO
1
��3 0�
Re-roofs
Signature of Ap m/Conuactor ' 7_ T of Roof
MATERIALS DISCLOSURE Type
Will the applicant or futute building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7All roofs shall be inspected prior to any roofing material being installed.
[3Yes
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
.nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
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
does not currently have a tenant,that it is my responsibility to notify the occupant of the
require nh]ch must be met prior to issuance of a Certificate of Occ ancy. Signatur;of Applicant Date
Owner or authorized t
All roof coverings to be Class"B"or better
arc
CITY OF CUPERTINO
A01 Odi +
REPIPE/SEVENS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM / �� 7
APN # -6 L+ 2,—
+ 2— I L- ,(DL - . 4N)�T-
Buildingding Address: y /
Owner's Name: / Phone#:
Contractor: Phone: License #:
3 ;' 7- 6 7741 7S
Contact: Phone: Cupertino Business License#:
] 7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: ��o /)� �' /
�'! /`Z ,,-/�T /�.L -L` c "7 0 1.1 -- - - '(�I
�S f� 1
Residential_ Commercial ❑
Cost of Project-
Qty.
.
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Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING