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07040211 CITY OF CUPERTINO BUILDING DIVISION PERMIT � 'RT� RATI©�1: PERMIT NO. BUIL(l�161"Es�ENHART LN TBD - TO BE DETERMINED 07040211 U S PERMIT ISSUE DATE OWNER'S NAME: ANH & DAO NGUYEN 06/19/2007 SANITARY NO. CONTROL NO. JNE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 04 p C LICENSED CONTRACTOR'S DECLARATION Job Description iUl(: I hereby affirm that I am licensed under provisions of Chapter 9(commencing :z�d with Section 7000)of Division 3 of the Business and Professions Code,and my license is HOUSE L EMO L I T I ON t y in full force and effect Lic.# 02 R r v�Z License Class p Date Contractor t ARCHITECTS DECLARATION i aa < 1 understand my plans shall be used as public records )yU U.y Licensed Professional < OWNER-BUILDER DECLARATION j< I hereby affirm that I am exempt from the Contractors License Law for the no following reason.(Section 7031.5,Business and Professions Code:Any city or county $ which requires a permit to construct,alter,improve,demolish,or repair any structure rn prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation x G that he is licensed pursuant to the provisions of the Comractor'sLicense Law(Chapter 9 Sq.Ft.Floor Area $9350 2 H (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged exemption.Any violadon of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 37515046 . Number Occupancy Type not more than five hundred dollars(1500). 0 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 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.). 0 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contraetoes U. cense Law docs 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 hereby affirm under penalty of perjury one of the following declarations: I hsve and will maintain a Certificate of Consent to self-insure for Warkcr 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. 0 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?c hundred dollars(1100) or less.) � I certify that in the performance of the "f.,whi is issued,I shall not employ any persan in any manner tot to Workers'Com rasa"on Laws of California.Date Applicant NOTICE TO APPLICANT:If, itioate,of Exemption,you should become subject to the Worker's ompensadon provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z'—' CONSTRUCTION LENDING AGENCY F-r I hereby affirm drat there is a construction lending agency for the performance of fZ> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name z Lender's Address U 0 I certify that I have read this application and state that the above information is LL r� correct.I agree to comply with all city and county ordinances and state laws relating to J Ubuilding construction,and hereby authorise representatives of this city to enter upon the above-mentioned properly for inspection purposes. a (We)agree to save,inti nify an9ccp harmless the City of Cupertino against r liabilities,judgments,costs expert m in any way accrue against said City + U z in consequence oC the rrryt Date ►� APPLICANT U STAND NO YG L COMPLY WITH ALL NON-POINT Issued b is SOURCE RE LATI S. z Re-roofE Signature of A for DaeT e Of Roof DISCLOSURE Type 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)? All roof.;shall be inspected prior to any roofing material being installed. 0 Yes 90 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 contamin;1N as c fined by the Bay Area Air Quality Management all new I naterials for inspection. District? C3 Yes u 1 have read the hazardous material r 6.95 of the Califor- nia Health&Safety Code,Sections 25 533 534.1 d that if the building does not currently have a tenant, t it' y r, ihi' �o otil'y the occupant of the requirement%which must be t pri u 11 fa e of occupancy. Signature of Applicant Date All roof coverings to be Class"B"or better Owner or authorircd agent Date -