07040005 77777777� 77777
CITY OF CUPERTINO TTji
BUILDING DIVISION, PERMIT � P � �
g $�; PERMIT NO
BUfL07040005
.
T'6qD(j 'S ULBERT SON DR TBD - TO BE DETERMINED 0 7 0 4 0 0 0 5
�J b PERMIT ISSUE DATE
OWNER'S NAME:
DONGLIN MI 06/12/2007
SANITARY NO. CONTROL NO.
JNE:
BUILDING PERMIT INFO
ARCHI7ECWENGINEER:
BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;'z'w with Section 7000)of Division 3 of the Business and Professions Code.and y license NEW S FL WL SINGLE STORY: 2014 '
cn License force Class d effect
in ctor
ARCHITECT'S Lic.a_ _ GARAGE: 481 ' -SANITARY I S SUNNYVALE' S
F� Date � DECLARATION JURISDICTION.
i C a 1 understand my plans shall be used as public records
i40
a H Licensed Professional
y a OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
.c O following reason.(Section 7031.5,Business and Professions Cale:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
s Z prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
x o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $458860
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 arty applicant for a permit subjects the applicant to a civil penalty of 375340_3 7 �Number Occupancy Type
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 Required Inspections
and Professions Cade: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 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:
have and will maintain a Certificate orConsent to self-insure for WorkeesCompen-
-
I- n,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 Workers 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 anc 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 o as to becom subject to the Workers'Compensation
Laws of California.Date
Applicant—i"fl ./ �r 1
NOTICE TO APPLICA?".T.aficr 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
(-r rte. I hereby affirm that there is a consuuction lending agency for the performance of
fZ> the work for which this permit is issued(Set:.3097,Civ.C.)
W Q Lenders Name
r7 z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
(t,►-" correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
lir (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.
APPLICANT UNDERSTANDS AND PLY WI NON-POINT Issued b3': Date - p 7
SOURCE REGULATI
e!4/12", Re-roofs
Signature of Appl' t/Co rot 9 Dale Type of Roof
H OUS MATERIALS DISCLOSURE yp
Will the applicant 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 roofs shall be inspected prior to any roofing material being installed.
❑Yes 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 defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
❑Yes �(o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safety Codc,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 am
rcquircmcnts which must be met prior to of a Ccrtificatc of Occupancy. Signature:of Applicant Date
a All roof coverings to be Class"B"or better
Owner or au oozed t I Dire