07080050 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �.C. I O�ZMATIOlY'
PERMIT NO.
BUILDING ADDRESS:
18760 LOREE AVE TBD - TO BE DETERMINED 07080050
PERMIT ISSUE DATE
R'S NAME:
VIN LUONG 09/06/2007
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
HOUSE/GARAGE DEMO BLDG ELECT PLUMB MECH
at D D D 0
p p LICENSED CONTRACTOR'S DECLARATION Joh Description
UI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
Z U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect.
Z License Class Lic.S
[-o Date Contractor
ARCHITECT'S DECLARATION
i < I understand my plans shall be used as public records
iaV
C y Licensed Professional
OWNER-BUILDER DECLARATION
3< 1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Cale:Any city or county
Pi 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 Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor Area
t=- (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 APN Number Occupancy Type
not more than five hundred dollars(5500).
❑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
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.).
as 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
Rr
1 Date
rWORKERS CO ON 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.
❑1 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 Workers Compensation Insurance artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic 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 soto comf ect to the Workers'Compensation
Laws of Califo ia.Date !!
App! 941,1 WalasF
NOTICE TO A CAM:If,after m'bNlTffiis Certificate of Exemption,you should
become subject to the Workers Cam up provisions of the Labor Code,you must
Oforthwith comply with such provisions or This permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
(~i Cn I hereby affirm that there is a cortsauctinn lending agency for the performance of
fSi> the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
U 0 1 certify that I have rad this application and state that the above information is
LL. — correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
W
ahove-mentiuncd 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 consequence of the granting of this permit.
APPLI NT UNDERSTA Date S AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR GULATIONS�
Re-roofs
(J'Signature of plic UContractorDale
A-f
HAZARDOU ER1ALS DISCLOSURE Type of Foof
Will the applicant or future building occupant store or handle hazardous material
lefined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
de,Section 25532(x)? ._r All roofs shall be inspected prior to any roofing material being installed.
❑Yes 00 no
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 rncd by the Bay Area Air Quality Management all new n aterials for inspection.
District? —J///���(((
❑Yes lett
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if the building
docs not c ntly have a tenant that my responsibility to notify the occupant Of the
requircmc hich must be met prior t h once of a Certificate or Occupancy. Signature of Applicant Date
.._ q, v
All roof coverings to be Class"B" or better
(Owner or authori- d agent Date