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07030125CITY OF (UFrlcT ury BUILDING DIVISION PERMIT BUILQ[NOG(tj�Dt2ESSC7.REENLEAF DR OWNER'S NAME: MINA HA JNE: ARCHITECT/ENGINEER: p zO LICENSED CONTRACTOR'S DECLARATION I U hereby affirm that I am licensed under provisions of Chapter 9 (commencing : Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is I <y in full force and eft3 Z License Class f 0 Lic.tf _,--7 r e�_ Contractor ? t Dam ARCHITECT S DECLRATION ,7-4 < I understand my plans shall be used as public records )yU------------- a yLicensed Professional a OWNER -BUILDER DECLARATION ja I hereby affirm that 1 am exempt from the Contractor's License Law for the _ 00 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 1 '? � prior m its issuance, also requires the applicant for such permit to rile a signed statement - a that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9 r H (commencing with Section 7000) of Division 3 of the Business and Professions Code) or i 3 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 not more than five hundred dollars ($500). 0 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 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.). 0 I, 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' B & P C for this reason 0 I am exempt under Sec. OwnerDate WORKER'S COMPENSATION DECLARATION TBD - TO BE DETERMINED TEMPORA=ZY POWER 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 Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work Cor 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 Work s Compensation Insurance carrier and Policy number are: t Policy Not CERTI CA OF E EMPTION 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, l shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must z forthwith comply with such provisions or this permit shall be deemed revoked. Z � CONSTRUCTION LENDING AGENCY E~" rA I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued (Sec. 3097, Civ. C.) W A Lender's Name �z Lender's Address I certify that I have read this application and stale that the above information is U 0 correct. I agree to comply with all city and county ordinances and state laws relating to U building construction, and hereby authorizr representatives of this city to enter upon the above-mentioned property for inspection purposes. a (We) agree to save, indemnify and keep harmless the City of Cupertino against t� (4 liabilities, judgments, costs and expenses which may in any way accrue against said City U z in consequence of the granting of this permit. ►-t APPLICANT UNDE ST SAND WILL COMPLY WITH ALL NON -POINT SO REGU , �o 4+7 ignature of pplican'Comractor ale 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. Section 25532(a)? 0 Yes ° Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? Cl Yes No 1 have road 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 docs not curritsrently have ant, th tis my responsihility to notify the occupant of the doesrequc t curr whit met r t i issuance o[ a Certificate of cupants 7-0-7- / /(o wrier or aut orized agent Date Sq. Ft. Floor Area Number Issued b;': �-' Re -roofs Type of hoof PERMIT NO. 07030125 PERMIT L55UE DATE 03/16/2007 SANITARY NO. CONTROL NO. BUILDING PERMIT INFO Job Description ,Required Inspections MECH occupancy iype Date All roofE shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signator-- of Applicant All roof coverings to be Class "B" or better Date 2 ITEMS OF 2 CITY OF C:UPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609015.00 DATE ISSUED.......: 03/L6/2007 RECEIPT #......•••: BSO)0000708 REFERENCE ID # ...: 07030125 SITE ADDRESS 20959 GREENLEAF DR SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER MINA HA ADDRESS ..........: CITY/STATE/ZIP ...: OPERATOR: bethe COPY # : 1 RECEIVED FROM RECEIPT INTERFACE CONTRACTOR TBE - TO BE DETERMINED LIC # 00096 COMPANY TBE - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP , TELEPHONE ........: FEE ID UNIT QUANTITY INOUNT PD -TO -DT THIS-REC- --NEW-BAL --------- - ----- 00 BTEMP FLAT RATE 1.00 62.10 0.00 62.10 0. EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 ------0_00 ------------------------------- TOTAL PERMIT 100.47 0.00 100.47 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 100.47 --------------- 100.47 VOICE ID DESCRIPTION -------- ----------------------- 103 UFER REFERENCE NUMBER -------------------- 1988 VOICE ID DESCRIPTION -------- --------------------------- 304 ROUGH ELECTRICAL - (� a( - CITY OF CUPEkTINO CITY OF CUPERTINO TEMP 1"30WER PERMIT APPLICATION FORM 07036)1,25 APN # Date: Building Address: -2 tc70 t� A, 22 . Owner's Name: Phone #: Contractor: Phone* Lk�� - 2 3 License #: ��"' 3 S� 3 Contact: Phone: Cupertino Business License #: z��s- Building Permit Info: Elect ❑ Job Description: Residential [ Commercial ❑ Cost of Project: Qty. if Fee Description Fee Group Applicable Fee ID BTEMP T -,mporary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING CITY Of ';UPEkTINO Buildin Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Devartment JOB ADDRESS: PERMIT 70 a OWNER'S NAME: PHONE 4u'7 GENERAL CONTRACTOR: `t- FAX # 3 U- I am not using any subcontractors: Signature ate li bl be tractors and com Tete the followin information Please check app ca a su on SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date Owner/ Contractor Signature