06070203 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
C�IR�.GTQ
PERMIT NO.
BUILDING ADDRESS: LAWS S CONSTRUCTION 06070203
20055 DE PALMA LA
PERMIT ISSUE DATE
^WNER'S NAME:
FELICIA & JOYCE CHOW 10559 FE
SANITARY NO. CONTROL NO.
PHONE:
(408).996-2353
ABUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
U
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect. DEMO ONE STORY S FDWL
Z License Class Lic.#
t p DateContractor
ARCHITECTS DECLARATION
i a< 1 understand my plans shall be used as public records
:96
Gy Licensed Professional
y OWNER-BUILDER DECLARATION
'>• 1 hereby affirm that t am exempt from the Contractors License Law for the
<2 following reason.(Section 7031.5,Business and Professions Code:Any city or county
,�,lti which requires a permit to construct,alter,improve,demolish,or repair any structure
z} prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
t= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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 i 0 0 Occupancy Type
not more than five hundred dollars(5500).
❑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
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
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 and fe�` B&P C for this reaso
ool
`wner , Date
ATION DECLARATION
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 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 arc:
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'ssued,I shall not
employ any person in any m r to come subject o rs' ompcnsation
Laws of California.Date
Applicant
NOTICE TO APPLICANT- fw ing tes Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
z. CONSTRUCTION LENDING AGENCY
(.r rCn� I 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.)
W A Lender's Name
L'~ Lenders Address
Pz
U C) I certify that I have read this application and state that the above information is
[L 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. /117
>''a (We)agree to save,indemnify and keep harmless the City of Cupertino against
„E ty fA liabilities,judgments,costs and expenses which may in anyway steric against said City
U Z in consequence of theffN .
of is rmit. Date
►� APPLICANT UNDD AN WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULA
o Re-roofs
Signature of Applican o Dare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
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
':odc,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes XNo
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? ,t
❑Yes �}No
1 have read the hazard
doous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of occupancy. Signature Of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Date