07100099BUILDING DIVISION PERMIT
Y WAY
PERMIT NO.
TBD — TO BE DETERMINED 07100099
OWNER'S NAME:
PERMIT ISSUE DATE
DAVID TSAI
10/15/2007
SANITARY NO. CONTROL NO.
PHONE:
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 c LICENSED CONTRACTOR'S DECLARATION
ut p 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
a y in full force and effect.
Z License Class Lic.lf
Dale Contractor
ARCHITECTS DECLARATION
a I understand my plans shall he used as public records
aV
U. y Licensed Professional
O a OWNER -BUILDER DECLARATION
w ,,
res 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
%Pi which requires a permit to construct, alter, improve, demolish, or repair any structure
Z y prior to its issuance, also requires the applicant for such permit to rile a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
t=- m (commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
!4 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
not more than rive hundred dollars ($501).
❑ I, as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the structure is notintended or offered forsale (Sec. 7044, Business
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
1, as owner of the property, am exclusively contracting with licensed contractors to
construct 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 Contactors
License Law.
❑ lam exempt un , B & P/C for this mason
Owner /DL ✓ Date (O ZZ p
( WORICERISCO PUPURSATIOIJ5ECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consentlo self -insure for Workers 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 Workers 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 Polity number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is far one hundred dollars ($101)
or less.)
Job Description
ADD COVERED PORCH, REMODEL 1 & 2 BEDROOMS
Sq. Ft. Floor Area $12000 Valuation
31602034jV64Number Occupancy Type
Required Inspections
I certify that in the performane��rr-p( to work for which this permit is issued. I shall not.
employ any person in a93. naso to be me s 'ecI to the Workers' Compensation
Laws of California at
Applicant
NOTICE TO APPLICANT: If, after making i c rricatc of Exempt n, you'shoufd
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.
O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
�i > the work for which this permit is issued (Sec. 3097, Civ. C.)
A Lender's Name
a M-. Lender's Address
J I certify that I 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
C) U building construction, and hereby authorize mpresentatives of this city to enter upon the
ahovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Hc/1 liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit
—+ APF.LICANT UNDEISTAN9&7? Q WILL COMPLY WITH ALL NON -POINT Issued by:
Sfgnaturcof Applicam/Contractor — - Date
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
Code, Section 25532(a)? ',�.0
❑Yes fThu
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
District?
❑ Yes u4co
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
Zdocs ave a ten3m is my responsibility to notify the occupant of the
ments whi st bgfteWrior t issuance of a Ccrtiricate of Occupancy.
or authorized agent (/' - r Date
Re -roofs
Type of Roof
Date r,, L/ - 2-'2 —c
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
-
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