06090001 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � AM0, 74
BUILDING ADDRESS: PERMIT NO. 06090001
10184 RICHWOOD DR
PERMIT ISSUE DATE
^WNER'S NAME:
YOUNG JIM KIM 10'/11 /200e
PHONE: SANITARY NO. CONTROL NO.
ABUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
a 0 a a
p p LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 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
e- in full force and effect. ADD 480 ' MASTER SUITE-161 ADDITION PORCH.
o ? License Class LM•8
t p Date Contractor
,ter ARCHITECTS DECLARATION
i 1 understand my plans shall be used as public records
>yU
uO H Licensed Professional
m OWNER-BUILDER DECLARATION
'> 1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 703 1.5.Business and Professions Code:Any city or county
% which requires a permit to Conswct,alter,improve,demolish,or repair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $103514
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rive hundred dollars($500).
[11.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,BusinessRe 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.).
1,as owner of the property,am exclusively contracting with licensed contractors to
k-struct the project(Sec.7044,Business and Professions Code:)The Contractors 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.
❑1 am exempt under Sec. B&P C for this reason
1wner Date f
Olt, a
WORKER'SICOMPENSATION DECLARATION
1 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 for which this permit is issued.
❑1 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. 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.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Califomia.Date
Applicant VO� f:1)L nIN
NOTICE SJ
IC after making this C nilicatc o cmption,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 OCONSTRUCTION LENDING AGENCY
[~t 1z I hereby affirm that there is a construction lending agency for the performance of
Ix the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lenders Address
V 0 1 certify that I have read this application and state that the above information is
w correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rF- 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 ' 7
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: /!
SOURCE REGULATIONS.
/o ZlRe-roofs
Signaur of App i�ontractor ,
t Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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.
C3 Yes ANo
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 materials for inspection.
District?
❑Yes O 11
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc,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 which must be met pit o�'`'issuance of a Certificate of Occupancy. Signature Signature of Applicant Date
�V�u/o All roof coverings to be Class'B"or better
Owncr or authorized agent Date