07100109 CITY OF CUPERTINO y^ ' � �
BUILDlNG DIVISION PERMIT 1�:��.RX �:���RM�T�iQN
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BUILDN ADDRESS: PERMITNO.
�Z�592 MC CLELLAN RD ALL AME�ICAN BUILDERS 07100109 �
PERMIT ISSUE DATE
'.R'S NAME:
i�lELODY FARQUAR CHANG 5871 WI:vFIELD BLVD
SANITARY NO. CONTROL NO.
PHONE:
(408) 2�4-5100
BU([.DING PERMIT INFO
ARCHITECi/ENGINEER:
BLDG ELECT PLUMB MECH
� � � �
i p p LICENSED CONTRACTOR'S DECLARATION JOb DeSCilptl0❑
: V� I hcreby aRirm �hat I am liccnsed undcr pravisions oC Chaptcr 9(commcncing
;z� w ithSecaon7ocw)afDivision3ofihcBusincssandProtcssionsCodc.andmy�iccnscis KTCHN R�,MODL (NON STRUCTURAL) , BATHRM REMODL (NON
'< a in fuli forcc and ef Fec
��z [,icenscC� �ic.� STRUCTU?�AL) & MODIFYING CLOSET FOR WASHER/DRYER
: F � pa� Cont[actac
� ARCHITECI'S DECLARATION COMBO
j� Q I undcrs�and my plans shatl bc used as public records
)aU
' u. F' Licenscd Profcssional
`� < OWNER-BUILDER DECLARATION
°}� 1 hcrcAy alTirm that 1 am eacmpt frum ihc Contranors Liccnsc Law far �hc
� p o (ollowing rcason. (Scctian 7f131.5, Busincss and Pro(cssions Cw1c: Any city or rnunty
<°„ � which requires a pcanit to conswct, altcr. improvc. dcmoli.ah. or rep�ir any suuctucc
° Z} prior u� i�s issuancc, also rcquircs ihc applicant far such permit ia filc a signcd sta�cment Valuation
� x a U�at he is iiccnsed pu�suant to the prov�sions ot the Conuacwr's [.iccnsc law (Chapter 9 3q. Ft. Floor Area $ 2 4 8 2 7
� F- $ (commcncing wi�h Scnion 7000) of Division 3 of ihc Busincss and Profcssions Cadc) or
i �.. that he is ezemp� thcrefrum and ihe basis (or the alleged exemption. Any violaaon o[
Section 7031.5 by atry applicant fo� a pe�mit subjecu ihe applicant to a civil penalty o( Number Oeeupaney Type
not morc than fivc hundred dollars (5500). 3 5 9 18 Q 1. ���
❑ I, as owner o[ Uie propecty. ar my empioycu with wages as their sole compensadon,
will do the work, and ihe struducc is not intended er effeeed for sak (Sec. 7044. Businest Required Inspections
and Professions Codc: The Conuactor's License Law does not spply w an owur of
propeny who builds or improves thercon, and wha does such work himsel[ or Uwugh hia
own employccs, providcd that wch improvements are not inw�ded or ollered for sak. If,
Aowever, the building or improvement is sotd within one year oC completion, drc owneo-
builder will have the burdu+ of proving �hat he did not build or improvc [w pmpose af
salc.).
❑ I, as owner oC the property, am exctusivtly contracGng with licensed conUUtas W
construa the project (Sec. 7044. Business and ProCcssions Code:)'Rie Coatr+crnrs Li•
ccnse Law docs oot apply to an owner of propeny w6o builds ar improves t6e�, and .
who conuacts Car such projec�s with a convactor(s) licensed pursuant to the Conuactors
License Law.
❑ I am aempi under Sec . B� P C(or �his reason
er Date _.. -
WORKER'S COMPENSATiON DECLARATION
I hercby �rm under penally ot perjury one o[ �he following doclazatians:
❑ I hsoe and will mainwin a Ceni6cate of Consent to sel(-insu�c for Workers Compen-
ution, as providcd for by Section 3700 of the Labor Code, for ihe perfom�ance o( We
work for which U�is permi[ is issucd.
❑ I havc and will maintain Workcr's Compensation Insunncc, as myuired by Scction .
3700 oC ihc Labor Codc, for �hc performancc of the work for which this pern�it is issued•
My Work C�ompensa�tion Insucance nrtier and Policy number are: �
Carrier.�)!�/�� T'I)/�.�� PoliryNo.: 7�3��° �
CERTIFlCATE OP EXEMP'I'(ON FROM WORKERS'
COMPENSATION iNSURANCE
([l�is scction necd not Ac complctcd if the permit is fa� onc hundred doilars (5100)
nr Icss.)
I cenify thxt in thc performance of thc work for which �his permit is issued, I shall not
e�ploy any persan in any manncr so az w bccomc subject to �he Workcrs' Compcnsation
Laws of Califomia. Date
Applicant
N01'ICE TO APPLICAM: If, af�cr making ihis Ccrtilica�c of Ezcmptian, you slwuld
become subject a the Worker's Compensation provisions of the Lahor Code, you must
� O forthwith comply with such provisions or this permi� shall bc dccmcd rewked.
z ""' CONSTRUCTION LENDING AGENCY
(- �- 1 hcreby afiirm ihat thcre is a consuuction knding agcncy 1'or thc perfortnancc of .
Q.! � thc work fur which this pertnit is issucd (Scc. 3097, Civ. CJ
W� A L.endcr'S Namc
� � L.cnder's Address
U 0 1 cenifY ihat t havc rcad ihis application and staic that ihc abovc info�mation is
w ►-� cortcct. 1 agree to comply with all city and county orJinances and su�e laws relating w
rJ U building consWCtion, and hereby authoriie �epresentatives of this city to enter u�n thc
� W abovc-mcntioncd property (or inspcction puqwses.
a (Wc) agrce to save, indcmni(y and kecp harmless the City of Cupertino against
�.� � liabilities, judgmcnts, costs and expcnscs which may in any way acccuc agtinst said City
U z in consequcncc ot Uic granting of �his permit. D1tE
►� APPLICANT UNDERSTANDS AND W1LI. COMPI.Y WITH ALL NON-POINT Issued by: �'� `�
SOURCEREGULA
a�� Zc�s Re-roofs �
SignuurcofApplican ontractor �a� T ofF.00f
HAZARDOUS MATERIALS D[SCLOSURE }��
Will Ihc applicant or futurc building acupant uorc or handlc ha•rardous ma�crial
�s dcfincd by 1he Cupenino Municipal Codc. Chapler 9.12, and �he Health and Salery
�, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
o Y� � ,
�II �hc applicant or fuwrc building occupant ux eyuipmcnt or dcviar which
If a roof is installed without first obtaining an inspection,l agree to remove
cmi� harardous air comaminan�s as dcfincd by the Bay Area Air Quality Managcmcnt all new n.aterials for inspec ;t0[l.
��su���? ��
❑ Yes �y'rvo
1 havc rcad U�e ha�ardcws materials requircmcn�s unckr Chap�er 6.95 af ihc Califo�-
nia Hcallh & Satcry Cadc, Scctio�s 25505, 25533 and 25534.1 mdcrstar�d �hat it ihc bui�d�oB
docs not curtcn�ly havc a �cnan4 ihat it is my responsibility W nodfy �hc occupant of thc
myuirc whic n��l «v�o�w�u���orac��;r�a�oro��P�r. Signature ofApplicant Date
5 ��---�� ������ All roof coverings to be Class "B" ar better
Owncr w au�horizcd agcnt ���