07010127 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C�1 'TI�AT ?R I�tt?RMT�ON•
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: ATE
,, CHAN, HENRY 1447 HI.MPTON DR. 01/22/2007
NE: SANrrARY NO. CONTROL NO.
(408) 6( 6-5298
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
u(= I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
=z rz� with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMPORI.RY POWER POLE
Ow- in full force and effect.
j ? License Class Lie.#
in Date Contractor
a ARCHITECTS DECLARATION
a< 1 understand my plans shall be used as public records
�aU
U.ti Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m Pi which requires a permit to conswct,.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 Sq.Ft.Floor Area $200
Valuation
Y F- (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 any applicant for a permit subjects the applicant to a civil penalty of N Number Occupancy Type
not more than five hundred dollars(5500). 3 6 61 1 0� 8 •-W
❑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 sale(Sec.7044,Business Required Inspections
and Professions Code: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 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.).
❑1,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&P C f rnthis
Owner DNe 1 2 a
WOR COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑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.
❑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 Workees Compensation Insurance carrier and Policy number arc:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need riot be completed if the permit is foronc hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so at to become subject to the Woky,'Contipensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exe ption,Jou sh Id
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(••d'�.. 1 hereby affirm that there is a construction lending agency for the performance of
ptS the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Lender's Address
U O 1 certify that I have read this application and state that the above information is
(3. " correct.1 agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives or(tis city to enter upon the
a ahove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AIlMil
OINT Issued b-r: Date 2 Zz
SOURCE REGULATIO S,Jj
Re-roofs
Signature of Applicant/Cbnfractor I Datd
HAZARDOUS MATERIALS DISCLOSURE Type of'roof
Will the applicant or future 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)? All roof, shall be inspected prior to any roofing material being installed.
El Yes WN.
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 I naterials for inspection.
District?
❑Yes QA u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Section 25505,25533 and 25534.1 understand that if the building
does not curcntly*mbc_ffkct
am,ghat it is my responsibility to notify the occupant of the
requirement prior to issuance of a Certificate of Occu Signatur,'of Applicant Date
'VAll roof coverings to be Class"B"or better
Owner or author arc
p oto D
r CITY OF CUPERTINO
TEM PO'S'ER
CITY OF
CUPEkTiNO PERMIT APPLICATION FORM
APN# 3(o U y ( ` _ � Date: ` 2
Building Address: .__
Owner's Name: CE J Phone #: .48 _ 3r
Contractor: Phone: License#:�
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Contact: Phone: C� Cupertino Business License#:
Building Permit Info: __
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Elect
Job Description: A z�Q-T o o,
Residential Commercial ❑
Cost of Project: oma
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Tem orary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING