07050282 CITY OF CUPERTINO
BUILDING DIVISION PERMIT GITR� QIiMATIf�N'
PERMIT NO.
BUILDING ADDRESS:
20896 ELENDA DR ALICE TPN 07050282
PERMIT ISSUE DATE
OWNER'S NAME:
ALICE TAN 2672 BASiSHORE PKWY #702 06/15/2007
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
c p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
ay with Section 7000)of Division 3 of the Business and Professions Code,and my license is HOUSE DE M0
H in full force and effect.
? License Class Lic.#
Dae Contractor
ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
uJ U
'
W.F Licensed Professional
t OWNER-BUILDER DECLARATION
> 1 hereby affirm that I am exempt from the Contractor's License Law for the
p 00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
7 rZ which requires a permit to construct,alter,improve,dcmolLch,or repair any structure
?Z r prior to its issuance,also requires the applicant for such permit to file a signed statement t' .Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 tq
.10
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or $8000
!WE 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 3263002-
( Number Occupancy Type
not more than five hundred dollars($500).
❑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 We.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.).
I,as owner of the property,am exclusively contracting with licensed contractors to
nsouct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds of improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
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:
❑I have and will maintain a Certificate of Consent to self-insure for Workers 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 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 forone 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 /r
NOTICE TO APPLICANT• er maki tsCcniricatc 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
F— tom. I hereby affirm that there is a construction lending agency for the performance of
pG> the work for which this permit is issued(Sec.3097,Civ.C.)
Wil.Q Lender's Name
Lenders Address
Z
U C) I 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
O U building construction,and hereby authorise representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r�r liabilities,judgments,toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date =C�
►" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATI NS. �
Re-roofs
SignatureApp' (/Contractor Dale Type of R sof
HAZARDOUS MATERIALS DISCLOSURE
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,Section25532(a)7 All roofs:hall be inspected prior to any roofing material being installed.
❑Yes No
building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant a
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new m iterials for inspection.
District?
❑Yes u
1 have read the hazar ms materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Code,Sections 2M5,25533 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 must be met prior toissuance ofaCertificate ofOccupancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or a64y6h7_ed age6_.�— Dare