07030134 CITY OF CUPERTINO �t 7�
BUILDING DIVISION PERMIT 1.� ��i �1t IORIV�ATIQN
BUILDING ADDRESS: PERMIT NO.
7552 DUMAS DR DRAIN IIOCTOR 07030134
n"'NER'S NAME:
PERMIT ISSUE DATE
11kLBERT LIU 1775 WINCHESTER BLVD 03/19/2007
PHONE: SANITARY NO. CONTROL NO.
(408) 3-, 0-3082
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a O O O
0 Z LICENSED CONTRACTOR'S DECLARATION
'o o Job Description
i U 1 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 SEWER CLEAN OUT
t a a in full force and effect. /_ 7 ��
j License Class Lic.# 6 7
`p Date '3 14 -0-7 Contractor
a ARCHITECTS DECLARATION
i z< I understand my plans shall be used as public records
>yU
U.y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
rZ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z> prior to its issuance,also requires the applicant for such permit to file a signed statement
_G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
r (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3500
L 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 Number Occupancy Type
not more than rive hundred dollars(5500). 3 5 9 2 6 0 C'3 .
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 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 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 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- f
cense taw 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 Convector's
License Law.
0 I am exempt under Sec. B&P C for this reason
jeer Date ` r�"lift
WORKER'S COMPENSATION DECLARATIONIf,
I hereby affirm under penalty of perjury one of the following declarations: VVVV ✓ �f
0 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 r 1�
�` ll
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 Worrkees Compensation Insurance carrier and Policy number are: t
Carrier. 10a eg—7h SW Ralf Policy No.: 6J ��D 1-0 -1,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one 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 Workcrs'Compensation
Laws of California.Date
Applicant
T
NOTICE O APPLICANT:If,after 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
Fr C,4,) 1 hereby affirm that there is a constructinn lending agency for the performance of
Clr> the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
z Lenders Address
U O I certify that 1 have read this application and state that the above information is
— correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
� nWi ahovc-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
.F"„4 to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. L
�+ APPLICA DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b„: Date ,� Si
S/ RCATION /
. J — (
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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
,role,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
❑Yu �!o
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 Materials for inspection.
District?
❑Yes
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 i is my rcsponsibilily to notify the occupant of the
re m rch m uance of a certificate of Occupancy. Signator<;of Applicant Date
3.f� D All roof coverings to be Class"B”or better
O cr or xh-o-d-zeeagent Date
CITY OF C;UPERTINO
r REPIPE/S V E /MAIN SERVICE
a1 OF v
,UPEkTINO PERMIT APPL[CATION FORM
Date:
Buis 5 2 rem
L
Owner's Name: hone#: 2 1yo�l ^72s -032
Contractor: Pone: License#:
� /—7�'c��2 3 cense#:
Contact: Phone: Cupertino�Bfusine sy
ce
Building Permit Info: i �j C eav� OU w
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of Project:
0
Qty. if
Applicable . Fee ID Fee Description Fee Group
BPERMFEE 131dg. Permit Fees BUILDING
BPGAS cJas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER ;3ewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC 3usiness License BUILDING