07030009 CITY OF CUPERTINO = ' �
BUILDING DIVISION PERMIT ���Rl���fl�Z����'`�`T���''
, :: _ ,.
PERMIT Na.
BUIL�r�csD��s�Y AVE TBD T J BE DETERMINED 0 7 0 3 0 0 0 9 .
OWNER'S NAME: PERMIT LSSUE D'4TE
HENRY WU � 05/23/2007
�NE: SANITARY NO. CONIROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECf PLUMH btECH
� 0 0 0
i O p LICENSED CON7RACTOR'S DECLARAT[ON
;v F. I hcrcby aCfirm that I am licenscd unckr pravisions of Chapicr 9(commcncing Job Description
;z� with Scction 700U)olDivision 3 of�hc Busincss and Profcssions Codc,and my liccnsc is ADD 9 41 ' . 2 BEDROOMS� 2 BATHROOMS� 1 L I V I NG ROOM�
:�y in full force and ef(ecL
��,� LiccnscClazs ���.# 1 DININ� & 1 LAUNDRY
�F'� �a� ARCHITECI'SDECLARATION REMODEL 1233 ' : CONVERT PARTIAL GARAGE INTO LIVING
i a.�
a 1 undcrstand my plans shall bc uscJ as public rccords
�yU
°u.y Licenud Profcssional
�y� OWNER-BUILDER DECLARATION
t hcreby alTirm that I am cxcmpt trum thc Contractor's Liccnsc Law Cor thc
�p O following rcason.(Scction 7031.5,Busincss and Profccsiuns Calc:Any city or coun�y
�,�,P�i which requires a pertnit to conswct,altcr,improvc,dcmolish,or repair any suucturc
°Z� prior to i�s issuancc,alsu rcquircs thc applicant tor such permi�to filc a signcd statcmcnt
�_� thai hc is liccnscd pursuan�to thc provisions of ihc Contractur's Liccnsc Law(Chaptcr 9 Sq.Ft.Floor Area Valuation
�F$ (cammencing wi�Section 7000)of Division 3 of the Business and Pro(cssions Code)ur $3 3 214 8
L�.. that he is exempt Neicfrom and ihe basic for the allegcd exempdan.Any violation of
Section 7031.5 by arry applicant for a pefmit subjccu�he applicant to a civil pcnaity of Number Occupancy Type
not more than fivc hundred dollars(5500). 3 5 9�3�4� �
❑I,as owner o(tlie propeny,or my cmployces with wages az their solc compensadon,
willdothcworkandthestcuctureisnotintendedoroE[erodforsalc(Sec.7044,Business Re uired Ins ections
and Pro(essions Code:The Conuactor's Lianse Law docc no[apply w an owner of Q P
propeny who builds or improves�hercon,and who does such work himsel(or through his
own emplayccs,providcd that such improvements are not intended or otTered(or saie.lf.
however,the building or improvement is wld within one year oC compledon,Ihe ownerv
builder will have the burden of proving�Aat hc did not build or improvc for purpose oC
salc.).
❑I,as owner oC the property,am exctusively conuacting wiUi licensed conuutors to
consnuct the project(Sec.7044.Business and Pro(essions Code:)The Coatrutor's Li-
ccnse[aw docs not apply lo an owner of property who builds or impmves Ihereon,and.
who conuacts for such projects with a contractoKs)licensed pursuant W�he Contractor's
License Law.
�I am eac t�Lndu S ,B 8c P C t �his uon
Owner pak� 3
OR COMPENSATION DECLARATION
I hercby afGrm under penalry of pery'ury onc o(the fallowing declarations:
❑1 hare and will maintain a Cenificatc of Conscnt to sclf-insme for Workcrs Compen-
sation,as providcd for by Section 3700 of the Labor Code,for Ne performancc of thc
work for which Uiis pertnit is issucd.
❑I havc and will maintain Worker's Compensation Insunncc,as reyuired by Scction
3700 oC the Labor Code,Cor U�c performance af the work for which this pe�mit is issued. �
My Workers Campensauon lnsurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPIiON FROM WORKERS'
COMPENSA'flON 1NSURANCE
(This section necd not bc completcd if tAe permit is for anc hundred dollars(5100)
or Icss.) '
1 cenify thai in the performance of the work for which Uiis pertnit is issucd,1 shall noe
employ any person in any manner so az co sybjccyt��rs'Compcnsation
Laws of Califor D�Ic�„�+� `i /
Applicant
NOTICE i i u '�catc of Ezcmption,you should
become subjcct W�hc Workcr's Compcnsation provisions of thc LaAor Codc,yau must
�O forthwi�h comply with such provisions or this permit shall bc dccmcd revolccd.
z'"" CONSCRUCTION LENDING AGENCY
E-r►�-� 1 hcreby a[lirm�hat there is a conswc�ion Icnding agcnry(or thc perfortnancc uC
p�, � ihc wurk for which ihis pertnit is iuucd(Scc.3097,Civ.C.)
W� Q Lendcr's Namc •
�z L.cndtr's Address
(�0 1 certi(y�hat t havc rcad this application and siatc that thc a6ovc infortnadun is
� ►" corrcct.1 agrce�o comply with all ci�y and county ordinances and siate laws rclating to
O U building conswction,and hereby authori�e rcprcsenta�ives of this ci�y to enler upon the
�a ahovc-mcntiuncd properry for inspccdon purposes.
(Wc)ag2e to save,indcmnify and kccp harmless the Ci�y of Cupertino against
�� liabilitia,judgmcn�s,cos�s and expcnscs which may in any way acccuc againsl said Ci�y
V z in consequcnce oC the granting of ihis mit.
�"'� APPLICA D AND iLL MPLY WITH ALL NON-POINT Issued by: Date
SOUR E, IONS.
L— � Re-roofs
Sign HAZAR OUS MATERIALS DISCLOSUR e� Type of R�of
Will ihc applicant or futurc building occupant srorc or handlc harardous malcrial
az dcfined by thc Cupertino Municipal Codc.Chaptcr 9.12,and thc Hcalth and Safcty
Codc.Scction 25532(a)? All roofs i;hall be inspected prior to any roofing material being installed.
❑Y� �
Will ihc applicant or futurc Duilding accupant usc eyuipmcnl ar dcviccs which If a roof i:;installed without first obtaining an inspection,I agree to remove •
emit ha•rardnus air conuminan�s u defined by the Bay Arca Air Quality Managcmcnt all new m 3terials for inspection.
Disuici?
O Y� �
1 havc mad the haiardous maicrials rcquircmcn�undcr Chap�cr 6.95 of�c CaliCor-
niaHcalih&Safc odc,Scctions U5.25533and25534.1undcrstandihaziCihcbuilding
docs nat w Uy havc a tcna u my res nsi6iliry w nodCy thc occupant of ihc
rcquire whi e rtoissuancc faCcrbfica�cof up� . Signature ofApplicant Date
i3 All roof coverings to be Class"B"or better
O r authori�r Datc