07030034 CITY®F C'UPi"i"'i iO
BUILDING DIVISION PERMITRA IF ?RMTAE�N'
PERMIT NO.
BUILDING ADDRESS: 07030034
10600 JOHANSEN DR TU NGUYEN
PERMIT ISSUE DATE
OWNER'S NAME:
WEN PING LIU 5309 ASILOMAR Q IT 0-4/06/2007
SANITARY NO. CONTROL NO.
JNE:
(510) 487-6170
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MEECCHH
i p Q LICENSED CONTRACTOR'S DECLARATION Job Description
W P I 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's TEMPORARY POWER POLE
t=y in full force and effect.
t n? License Class Lic•#
Date Contractor
F ARCHITECTS DECLARATION
7 a< I understand my plans shall he used as public records
)qV
u.i- Licensed Prufcssional
:O< OWNER-BUILDER DECLARATION
aI hereby affirm that 1 am exempt from the Contractor's License Law for the
n O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to construct.alter,improve,demolish,or repair any structure
prior w its issuance.also requires the applicant for such permit to file a signed statement Ft.FlArea Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 !q. Floor $581
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
W that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 37536013
Number
not more than five hundred dollars(5500).
❑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 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.).
❑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 f r this reason
1
Owner Dale
WORKER' OMPENSATION DECLARATION
4
I he affirin under ally of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for arc hundred dollars($100)
(ir less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to wn;su 'ct w the Workers'Compensation
Laws of California.
Applicant
NOTICE TO APP ANT:If,aft ing Otis crtifcate of Excmptimn,you should
become subject to Worker's C pensation provisions of the Labor Code,you must
Z forthwith comply th such provis� ns or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
(~- V) 1 hereby affirm that there is a construction lending agency for the performance of
r7 the work for which this permit is issued(Sec.3097,Civ.C.)
Lia A Lender's Name
z Lender's Address
[certify that I have read this application and state that the above information is
LJ.O cortect.I agree to comply with all city and county ordinances and state laws relating to
r� U building construction,and hereby authorise representatives of this city to enter upon the
W ahove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
�+ 6—
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT Issued by:
SOURCE REGU TI NS. /—
l...X-/ / Re-roof.
Signature of App t/ ontractor D T of Roof
HAZARDOUS ATERIALS DISCLOSURE ype
W ill the a plicant or future Iding occupant store or handle hazardous material
as defined by the upertino Munic' al Code,Chapter 9.12,and the Health and Safety
Code,Section 25 32(a)? All roof;shall be inspected prior to any roofing material being installed.
❑Yes ❑N
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 contaminants as defined by the Bay Area Air Quality Management all new Tlaterials for inspection.
Disrict?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Code,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 the
rcquireme is which must be et prior w issuance of a Certificate of Occu er- : S ignatul a of Appl icant Date
All roof coverings to be Class"B"or better
Owner or uthori-zed agent D te
�
^� CITY OF �CUPERTINO 3
TEW `OWER
CITY OF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: _ l
Owner's Name: Phone #-
Contractor: Phone: License #:
Contact: _ Phone-. Cupertino Business License #:
Building Permit I fo:
Elect ❑
Job Description:
Residential 9 Commercial ❑
Cost of Project: 4 L
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC E usiness License BUILDING