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CITY OF CUPER"1'IJ
BUII—tING DIVISION
UILDING ADDRESS:
OWNER'S NAME:
LIEHWUU WANG
ONE:
ARCHITECTIENGINEER:
PERMIT
360 MEMORIAL DR S
(866)293-3031
PERMIT NO.
40 01/18/
SANITARY NO.
BLDG
LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70()0) of Dut+yoyJ of the Business and Profcssiuns Codc. an y license is REPLACE WATER HEATER
in full
License CI ✓ Lic. N
Date _ Contractor
AR HITECTS DEC A ON
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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 rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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
and Professions Code: The Contractor's License Law does 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 Contractor's
License Law.
❑ 1 am exempt under Sec. B At P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
Av Workee&Comlpensadon Insurgnce carrier and Policy number are: - _ , ,//
/ -1'4-' I `+rsr__ COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z ' CONSTRUCTION LENDING AGENCY
F~ ►�-� I hereby affirm that there is a construction lending agency for the performance of
(� > the work for which this permit is issued (Sec. 3097, Civ. C.)
W0. A Lender's Name
2 Lender's Address
U 0 I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction, and hereby authorise 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
liabilities, judgments, costs and expenses which may in any way accrue against said City
U z in co nce of the granting of this permit.
�+ PP UNDERSTANDS A WILL COMPLY WITH ALL NON -POINT_
S fdULATIQNS.
Signa of AppIicanUContracTor Date
if HAZARDOUS MATERIA D SCLOSURE
Will the applicant or future building a pant ore or handle hazardous material
as defined by the Cupertino Municipal Codc, r 9.12, and the Health and Safety
Cale, Section 25532(a)?
❑Yes o
Will the applicant or,/U.building occupant use equipment or devices which
emit hazardous air contami7Lsdefined by the Bay Area Air Quality Management
District?
❑ Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Healdy* Safety Code, Sections 25505, 25533 and 25534.1 understand iho if the building
oes np(q(rrrentiy have a tenant, that it is my responsibility to notif a occupant of the
mn crit: which must bomtet o4dr-"uance of a Certific fAceu=cy. _ -7
Date
Sq. Ft. Floor Area
35922073 AffNumber
Issued 1
Re -roof
Type of Roof
$500
Required Inspections
1910RICC1i11110i7
BUILDING PERMIT INFO
valuation
All roo 's shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
coot
-UPEkTINO
I am not using any subcon
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Build:ine Department
r
P #
1-11-i��7-
'Y E ignature Y Date
Please check a licable subcontractors and coni lete the following information
Owner/ Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
Date
CITY oF
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Phone n
a53.6466
License #_
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