10060001 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10284 S STELLING RD CONI RACTOR:LISA WONG PERMIT NO: 10060001
OW"'FR'S NAME: LISA WONG 10284 S STELLING RD DATE ISSUED:06/01/2010
O .R'S PHONE: 4083290062 CUPERTINO CA,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F_ ELECT F PLUMB r
License Class Lie.# r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB-DESCRIPTION:REMODEL KITCHEN(132SQ)&MASTER
(commencing with Section 7000)of Division 3 of the Business&Professions BATH I IOSQ);NON-STRUCTURAL
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by Sq.Ft Floor Area: Valuation:$35000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN,lumber:35913094.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, `VITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issue by: Date:
Sign-cure Date
OWNER-BUILDER DECLARATION RE-ROOFS-
All ro As shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt m the Contractor's License Law for one of install:d without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my" employees with wages as their sole compensation,
will do the work,and the structure i not intended or offered for sale(Sec.7044, Signa ure of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I hav,read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Co4e,for the Califf Prnia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safet;1 Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. main ain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owlor auth r' ecj�,gppt: I v
become subject to the Worker's Compensation provisions of the Labor Code,I must ( �- Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I here Dy affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for w rich this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lend-r's Name
to building construction,and hereby authorize representatives of this city to enter
up- `tie above mentioned property for inspection purposes.(We)agree to save Lend:r's Address
it ,fy and keep harmless the City of Cupertino against liabilities,judgments,
co!,,.,,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal.Code,Section I und,:rstand my plans shall be used as public records.
9.18.
q_1
2 Licer sed Professional
Signature � Date