07100003 CITY OF CUPERTINO �- ' �T 7�
BUILDING DiVISION PERMIT t*:��� ���� ��T����`r��T���t' `
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PERMIT NO.
BUfLD �N�g���ESSBIXBY DR TBD — T�� BE DETERMINED 07100003 .
PERMIT LSSUE DATE
OWNER'S NAME:
WAI FUNG SHETYE 10/01/2007
SANITARY NO. CONTROL NO.
NE:
BU(LDINGPERMITINFO
ARCHITECT/ENGINEER:
BLDG EI.ECT PLUMB MECH
� 0 0 0
i p p LICENSED CONTRACfOR'S DECLARATION JOb D6SCTlptlOil
� v� I hcrcby afGrm �hat I am ticenscd undct pravisions oC Chaptcr 9(commencing
; Z, � with Scction 7000) of Division 3 of ihc Busincss and Profcssions Codc and my liccnse is EXTEND : JEW GA S L I NE FRM FURNAC E AREA TO F I RE PLAC E
; a y in full Corce and effec�
�� z t,icensc C�ass Lic. k FOR GAS LOG .
i t— � Dam Contrxar
ARCHITECI'S DECLARATION
i a a ( undcrstand my plans shall bc used as pu6lic records
)yU
' u. F' Liccnsed Prufcssional
� � � OWNER-BUILDER DECI.ARATION
>' 1 hcrcby alTirm �at 1 am cxcmpt Gum thc Comractors Liccnsc Law for thc
i p O following rcason. (Scction 7031.5, Busincss and Profcssions Codc: Any ci�y or county
�$�i which rcquires a permit to conswct, altcr, improvc, dcmolish, or rcpair any swcturc
� Z y prior w i� iscuance. also rcquires ihe applicant [or such permit io Gle a signed su�emeni , F[. FIOOI' AiC1 Valuation
< lhat hc is liccnscd pursuant to thc pmvisions of Ihc Conuac:tor's Liccnsc Law (Chaptcr 9 '>q � 6 O O
t ti� (commencing wiih Scction 7000) of Division 3 of thc Business and Profcssions Cadc) ur
��� that he is ezempt thcrefrom and ihe bazis Cor the alleged exemption. Any violaGon ot
SecUon 703I.5 by any applicant Cor a pennit subjec�a ihe applicant to a civil penalty of Number Oceupaney Type
n o t m o c e t h a n f i v e h u n d¢ d d o l l a r s ( S S 0 0). 3 6 9 � 9 � 1 ���
❑[, u awncr o( ttie property, a my cmployca with wages as their solc compensation,
wil! do �he wock. and ihe secuaum is not intended or offered for sale (Sec. 7044, Business Required Inspeetio ns
and Professions Cade: The Conuactor's License l.aw daes �rot apply w an owner of
propeny who 6uilds or improves thercon, and who does such work himulCor througA his
own employces. providcd that such improvemenLS are no[ intended or ollered for sate. I[,
however, the building or improvement is soid within one year of compleuon. �he owner-
builder will have the burden o[ proving �hat he did not build ar improvc tor pu�pose of
salc.).
❑ I, as owner of the propcny, am exclusively conhacting with liansed conuacwrs w
rnnstruct the project (Sec. 7044. Business and Professions Code:) The Contraccor's Li-
cenu Law docs not apply to an owner o( propeny who builds or improves iAeieon, and ,
who contrac�s Cor such projects with a con�ractor(s) licensed pursuant W the Contractor's
Liccnse Law.
❑ I am ezempt under Sec . 8& P C for this rcawn
Owner Date
WORKER'S COMPENSATION DECLARA170N
I hereby �rm under penalry of perjury onc o( the fallowing declarations:
(] I hsve and will maintain a CeniGcate of Consent to self-insure [or Worke�s Compen-
sation, az providcd for by Secdon 3700 of the Labor Code, for the performancc ot U�c
work for which Ihis pertnit is issued.
❑ I havc and will maintain Workers Compensation Insunnce, as �eyuired by Section ,
3700 0( the Labor Code, for �he performance of the work (or which this permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Camer. Policy No.:
CERTIF7CATE OF EXEMPIiON FROM WORKERS'
COMPENSATION INSURANCE
(fhis secUan necd not be completcd if the permit is for anc hundrcd dotlars (S 100)
or IessJ
i ceniCy that in thc performancc of thc work for which �his permit is issucd, t shall not
o�nploy any person in any manncr so u w bccomc subjcc� to ihe Workers' Compensation
Laws oC Califomia. Datc
Appliwnt
NOTICE TO APPC.ICAM: 1(, alYcr making U�is CeniGca�e of Ezemption, you shauld
become subjcct to thc Workcr's Compcnsation provisions of Uic Labor Codc, you must
, ,Z forthwilh comply wi�h such provisions or this pccmil shall bc dccmcd revokcd.
Z O CONSTRUCI70N LENDING ACENCY
E + .�-+ 1 hereby a1Ti �hat there is a conswction Iending for the perfurtnane.�c of .
�Y, � ihe wurk for which ' it is issued ( c. 309'1, Civ. C.
W A dcr's Namc
� z C.cn ddress
V � I ccrtily avc rcad �his application and sutc �hat the abovc infortnau is
w ►�" cortect. I agrce to comply with all city and county oniinances and state laws rela�ing w
� U building conswction, and hcreby authome represrnta�ivcs of this city to cntcr upon thc
� W abovomcntioncd property for inspccuon purposes.
a (Wc) agrcc to save, indcmni(y and kccp harmless �he Ciiy o( Cupertino against
H � IiabiliUu, judgmcn�s, cos�s and expenscs which may in any way accruc agains� said City
U,'� in consequcncc of thc granting of this permi� Date
�'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOURCE REGULATIONS.
Re-roofs
Signaturc of ApplicantlContractor �e� T of R oof
HAZARDOUS MATERIALS DISCLOSURE }��
Wi1116c applicant or Cuturc building accupant storc or handlc ha•rardous matcrial
az dcfincd by ihe Cupertino Municipal Code. Chap�cr 9.12, and the Hcal�h and SaCcty
Cock. Scction 25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
❑ Ycs ❑ No ,
Will thc applicant or futurc building occupant usc eyuipmcnt or dcviccs which
If a roof i� installed without first obtaining an inspection, I agree to remove
cmit harardous air conuminanLC as Jcfincd by lhc Bay Area Air Qualicy Managcmcn� all new m aterials for inspecrion.
District?
❑ Ycs ❑ Nu `
I havc rcad ihe hvarCcws maicrials requircmen�s undcr Chap�cr 6.95 of U�c Califor �A / J � ^' �� ���� / ���
nia Hcalih & Safcty Codc, Scctiau 75505. 25533 and 25534.1 undcrsund ihu if ihc buildin �I � �j —-
docs not curtcn�ly havc a tcnan�. Ihat it is my responsibiliry to no�fy �hc occupant of thc
rcyuircmcn�s which musi bc mei prior w issuancc o�a CcniGca�c of Occupanry. SlgIIdillre Of APpI1C3 Date
oa � . All roof coverings to be Class "B" or better
Owncr or authorizcd agcn�