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CITY OF CUPERTINO
DIVISION PERMIT
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BUILDING
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TBD TO BE DETERMINED
07070185
;R'S NAME:
PERMIT L5UEDATE
STEVEN LIAO
09/18/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
HOUSE DEMO
in full force and effect.
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Profusions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any stnrcture
prior to its issuance, also require the applicant for such permit to file a signed statement
Contractor's License Law (Chapter9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
$8500
(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
316 3 0 0 6 0 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500)
I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q P
ivill,dothework,andthestructureisnotintendedoro(feredforsale(Sec.704.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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractoes 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 Contractoes
License Law.
ason
❑ I am exempt under Sec B & PP C for Mason
2
Date —
_
WORKER'S COMPENSATION DECLARATION r
_•
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for rine hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manr)ca,5o_ be omeO �ecl a the Workers CompertsaGon
Laws of California. `��11 (�' 'j—T
Applicant o
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
forthwith comply with such provisions or this permit shall be deemed revoked.
)
' CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
Lender's Address
1 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
building construction. and hereby authorize representatives of this city to enter upon the
? above-mentioned property for inspection purposes -
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
r in consequence of the of this
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granting permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by Date
SOURCE REGU ON r-�-4
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Re -roofs
Signature of Applicant/Contractor Dale
HAZARDOUS MATERIALS DISCLOSURE
Type of P oof
Will the applicant or future building occupant store or handle hazardous material
- defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
de, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes 'tri
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new IT. aterials for inspection.
District?
❑ Yes Mo
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
requirements which f Occu
uiremust be metrior a isscc of a Certificate o
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Signature of Applicant ate
� 2pa�`'` D
All roof coverings to be Class "B" or better
Owner or authorized agent Dare