07020105 CITY OF CUPERTINO
BUILDING DIVISION PERMIT : GTR IiR( RM�TION
PERMIT NO.
1111_1�lyiTr"HAZELBR00K DR TBD - TO BE DETERMINED 07020105
PERMIT ISSUE DATE
OWNER'S NAME:
LI-ZEN TING & CHII-LUH CHEN 05/21/2007
SANITARY NO. CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
Vi= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Zw with Section 7000)of Division 3 of the Business and Professions Code,and my license is NEW 2 STORY S F DWL— 1ST F L• 2104 .2 ' 2ND F L•
I a o in full force and effect.
License Class Lie.s 1033 . 8 ' , GARAGE 639 . 8 ' , PORCH: 18 '
Date Contractor
F w ARCHITECTS DECLARATION
i a< 1 understand my plans shall he used as public records
)yU
'ay Licensed Professional
a OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
CCoo following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter,improvc,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
z} P Ft.Floor Area
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q $709458
2 t= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 32628052�°`t1�Number Occupancy Type
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.).
I,as owner of the property,am exclusively contracting with licensed contractors to
"eahstruct 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.
❑lam��KERS
ec .B&P C for this reason
O�roen Date
COMI)MA ON DECLARA'tI0
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 3710 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 are:
Cartier. Policy No.:
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,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Califorty
7 50 Applicant 'n
NOTICE T6XPFLIdAffr.If,alfcr making this t t o empttan,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, CONSTRUCf1ON LENDING AGENCY
(~t ce) I hereby affirm that there is a construction lending agency for the performance of
(li> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lenders Address
U 0 I certify that I have read this application and state that the above information is
V. " correct.1 agree to comply with all city and county ordinances and state laws relating to
Obuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments,costs and expenses which may in any way accrue against said City r 7
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
%. - 4< 9_::� _ fit/D Re-roofs
stunt of Apphcan ontractor Datef
HAZARDOUS MATERIALS DISCLOSURE Type of Loof
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 roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof s 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 materials for inspection.
District? f.
❑yrs o
1 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 it is my responsibility to notify the occupant of the
require which must be met prior to issuance of a Certificate of Occupanc. / Signature of Applicant Date
All roof coverings to be Class"B" or better
ne r authorized agent Date