07010147 CITY Off'CUPERTINO
BUILDING DIVISION PERMIT AT(�R:INEQRM€ TI�N
BUILDING ADDRESS: PERMIT NO.
1
OWNER'S NAME: PERMIT ISSUE DATE
RON HSU 1656 N KING RD 01/24/2007
JNE: (408) 251-6040 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
4 V 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
=Z iz with Section 7000)of Division 3 of the Business and Professions Code,and my license is SEWER CLEAN OUT
y in full force and effect `
v�z License Gass �-�3G Lic.0 7 �/
E
in Date - o Contractor fflfarP k C„rr
ARCHITECTS DECLARATION
a
U j� .1 u dcrstan y p s shall be used as public records
`C y Licensed Professional
n y OWNER-BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Contractor's License Law for the
L
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
e
.9 which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior w 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 Valuation
y $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $4500
y R E 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
not more than five hundred dollars(5500). 3750702 � .QB p y Type
❑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 docs not apply to an owner of Required Inspections
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 Guild 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.
❑I 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-
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 Workces Compensation Insurance,as required by Section AI, - -Z,
3700 of the Labor Code,for the performance of the work for which this permit is issued.M Worker's Com enation urance carrier and Poli number am:Cam'er: I°i L r,0�, Policy No.: LoQ7�e - O3
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 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
.J O forthwith comply with such provision or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-+►+ 1 hereby affirm that there is a contraction lending agency for the performance of
<Yi the work for which this permit is issued(Sec.3097,Civ.C.)
WIs.Q Lender's Name
.7 Z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives of this city to enter upon the
Uabout-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. /
t— APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC 1RryGULATGI Q NS.
!( dO_� o L a`1'o� Re-roofs
Signature of ApplicanNContractor Dam —J
HAZARDOUS MATERIALS DISCLOSURE Type of R)of
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)?
Yes �No All roofs,,hall be inspected prior to any roofing material being installed.
❑
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 m Iterials for inspection.
District?
❑Yes /11 No
1 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
rcquircmcnts which ust be t prior w iwuancc efa cer;fcate of Occupamcy. Signature )f Applicant Date
1 g k CZE- L 29-87
Owner or authorized agent Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
REPIPE/SEJrE; S/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # 3 /S 1�� , Date: -
07
Building Address:
Owner's Name: S Phone#:
Contractor: Phone: d? - �?W - yf72
. License #:
I J�-- c- ( � w1 �(c►g z - 6 a
73 -2- (o
Contact: r Phone: Cupertino Business License#:
4-
Building Permit Info: _
Bldg fel Elect ❑ Numb CEJ
Job Description:
Residential Commercial ❑
Cost of Project:
`� Soca
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 Se avers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING