07090146CITY OF CUPERHNO
BUILDING DIVISION PERMIT
BUILD�N�i ffVSS. SALEM AVE
OWNER'SNAME:
JANE CHUEH
JNE:
ARCHITECTIENGINEER:
i p Q LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of DivigtQn 3 of the Business and ofc i ns Cnd my license is
t y in full force and effect.
t 22 ? License ass Lic. #
F p pate Contractor
A CH 7s DECLAR ION
i a t 1 F' 'n
my plans shall be used as public records
)aU
U. y Licensed Professional
H OWNER -BUILDER DECLARATION
1 hereby affirm that t am exempt from the Contractor's License Law for the
p O following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to consuuct, alter, improve, demolish, or repair any structure
u z 0 prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
t= (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y 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 five hundred dollars ($500).
I, 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
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.).
O 1, 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 contractors) licensed pursuant to the contractor's
License Law.
❑ I am exempt under Sec. B dt P C for this reason
Owner Date
WORKER'S COMPENSATION 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 Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 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 Corn rasa ' n Insu cam rand Polity n rub are:
Carrier Polity No.:
I�ERTIFICATE OF EXEMPTION FROM WO K RS'
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 issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date —
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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. Q
Lender's Name
Lender's Address
1 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
building construction, and hereby authorise representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless a ity of Cupertino against
liabilities, judgments, costs and expenses which may'UP
ay accrue against said City
in consequence of the ting of this permit.
APPLICANT UNDSTAND AND WI WITH ALL NON-
SOURCEREGUL�'l7o14,1f 1 yj
Signature of App)[canUCon r Date
HAZ US MATERIALS DISCLOSURE j�
Will applicant ` tore building occupant store or handle h • l a al
as defined by c Cupertino Municipal Code. Chapter 9.12, and the Heal and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant r future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? r
❑Yes (QN6
,t Ji' I have read the hazardous materials re uun hapter 6.95 of the Califor-
nia Health &Safety Cod ,Sections25503334.I derstandthatifthc building
docs not currently h a tenant, that it bilit notify the occupant of the
requirements wh' ust be met prior anCe are of Occupancy./A
Owner or
PERMIT NO.
TBD — To BE DETERMINED 07090146
PERMIT ISSUE DATE
SANITARY NO.
Job Description
REVISION—EXISTING CEILING JOIST
G'L X06060251
,>q. Ft. Floor Area
342121021
Issued by:
Re -roofs
Type of Roof
7
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Valuation
$0
Type
Required Inspections
All roofs :;hall be inspected prior to any roofing material being installed.
If a roof i:; 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