07030119 .777777777777777777=:; 7.1
CITY OF CUPERTINO
BUT DIVISION PERMITPERMIT No.
11� ir� Tl� .
BUILgIPj('r,AQq( %REENLEAF DR TBD TO BE DETERMINED 07030119
OWNER'S LN25AlME:: PERMTT ISSUE DATE
WILLIE LU 05/02/2007
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
i o p LICENSED CONTRACTOR'S DECLARATION
%v I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z UW with Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMOLITION
y in full force and cffecL
o Latcn�lL�-�--Loom to All� ' T NEED CCNTRACTOR INFO
.Wa ARCHITECTS DECLARATION
7 a< 1 understand my plans shall be used as public records
)WU
U.y Licensed Professional
0 OWNER-BUILDER DECLARATION
< 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
m(Zi which requires a permit to construct,alter,improve,demolish,or repair any structure
z y prior to its issuance,also requires the applicant for such permit to file a signed statement
=a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $10000 Valuation
H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or X71 0 0 0 0
y 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 ofNumber Occupancy Type
not more than fire hundred dollars(M). 32630173 Vf
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 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 U.
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.
0 1 am exempt under See. B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
Q 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 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 Workees compensation Ittwnnce carrier and Policy numb re:
Carrier: S"���G M64 0% Policy No.:71AW.M16
CERTIFICATE OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE J
(This section need not be completed if the permit is for one hundred dollars(S 100)
or less.)
I cenify 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
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z h-.h CONSTRUCTION LENDING AGENCY
(-+►�- 1 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.)
Wei, A Lender's Name
]z L.cndees Address
U C-) 1 certify that 1 have read this application and state that the above information is
IL t— correct.I agree to comply with all city and county ordinances and state laws relating to
0 construction,consction,and hereby authorize representatives of this city to enter upon the
�U above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
t) liabilities,judgments,toss and expenses which may in any way accrue against said City
V Zn
corse ac"
of the granting of this permit.
APP A of
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S CE UL-AMI
L Itafr L Re-roofs
ignaturc of ApplicanUC tractor Date
HAZARDOUS MATERIALS DISCLOSURE Type Of R)of
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
Crate,Section 25532(a)? All roofs:hall be inspected prior to any roofing material being installed.
❑Yes Na
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 Arca Air Quality Management all new m Iterials for inspection.
District?
❑Yes \[]rNu
1 have read the hazardous ma►renals 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 it is my responsibility to notify the occupant of the
requirements whic4AIdmmet prior to iss ee e a Ce he f occupancy. Signature A Appl ieant Date
Owncro zcdagcnt a,� All roof coverings to be Class"B"or better