07110020 CITY OF CUPERTINO ����
BUILDING DIVISION PERMIT ;
.
,: ,_ . .
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PERMiT NO.
BUILDIN ADDRESS:
7478 FALLENLEAF LN CHUA, R��Y AND TAN, KNG KER 07110020 .
PERMIT ISSUE DATE
�ER'S NAME:
CHUA, ROY AND TAN, KNG KER 7478 FA�LENLEAF LN � 11/13/2007
SANITARY NO. CONIROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECC/ENGiNEER: ' BLDG ELECT PLUMB MECH
� 0 � �
� o a LICENSED CONTRACI'OR oECCaRarioN Job Description
� V I hcrcby affirm �hat I am liccnsed undcr provisians o( Chaptcr 9(commcncing
� withSccdon7000)o(Division3ofthcBusincssandProfcssiansCode REVSN OE' FOOTING IN FNDTN BET DINING & LVNG NEW &
�� y infullCorceandeftat �� � ROOF FRKG—ORIG# �7�4�223
� v� Z Licensc Clasa Contractnr
� F � Datc
ARCHTCECI'S DECLARATION
��< l undcrsunJ my plans shall be wcd u public records
�yU
� � y Licensed P�ufcssianal
y � OWNER-BUILDER DECLARATION
1 hcreby alTirm Uiat I am excmpt fn�m ihe Conuaaors Liccnu Law for 1hc
� p o [ollowing roason. (Section 7(Y! 1.5, Busincss and Profcssions Codc: Any city or county
�,°, Pi which ccquires a pcfmit to conswct, altcr. improvc. demolish. or repair any suucture
y" y prior io i�s issuancc, alu� mquires thc applicant for such permit to Glc a signctl stalcmcnt , Ft. FlOOf APCil Valuati on
Z< lhat Me is lianscd pursuanl to �he provisions of the Convactor's li��cnsc Law (Chaptcr 9 ��] � 0
Y u T - $(commcncing wilh Sccuon 7000) af Division 3 of Ihc Busincss and Profeuions Codc) or
y��, �ha� he is mcempt tM.�etrom and the batis Cor �he allegcd exempdon. Any viola8on of Oecupancy Type
Section 7031.5 by a�ry applicant Cor a permit subjects U�e applicam to a civil penalty of 3 5 9 2 8 0 2 0�� Number
not morc tNan fiw hundted dollars (SSO�.
❑ I. u owncr o[ tt�e property. ar my employces wiN wages u their solc compensation,
wiA do 1he work and ihe structme is not intended or otCeced forsale (Sec.7044 Business Required Inspections
and Pro[essions Cade: The Conuactar's Lianse Law das not apply to an owner of
property w6o 6uilds or improves �hertwn, and who does such work himaelf or Nmugh his
own employca. provided that such improvemen�s ue not in�ended or offered Ca sale. lf.
however, the building or impcovement is so1A W�W�n one year of compleGon, the owner-
builder will have the burden o[ proving �hat he did not build or improvc [or puryase of
saleJ.
❑ I. u awner ot the property. am acclus9vely conuacting wi�h licensed contracwrs to
construct the peojett (See. 7044. Businas and Professions Code:) The Contrxtor's Ir-
cense Iaw docs aot apply to an owner of property w6o builds or improves lheceon, and ,
who conuacts for sucA projects wiih a conuxtoRs) licensed pursuant to �he Convactor's
Licenae Law.
^[ am exempt under Sec. . B g P C for this n
.ier Daie � � �
WOR 'S COMPENSATION DECLARATION
I hereby ��m under penalty of perjury nne o[ �he foUowing declarstions:
❑ I 6sve and will mainuin a Certi6ca�e ot Consent a self-insure for Workcrs Compen-
sation, u providcd for by Section 3700 of the Labor Code, for �he pedormancc o[ the
work for which �his pertnit is issucd.
❑ I havc and will maintain Workers Compensation ►nsunna, as rcquired by Sccdon ,
3700 0[ the Lsbor Codc. Cw thc pcdormancc af �he work for which ihis pecmit is istued
My Worke�s Compensarion Insunncc carticr and Poliry number azc:
Camer. Poliry No.:
CgR7'IFICATE OF EXEMP110N FROM WORKERS'
COMPENSATION INSURANCE
(i'hu scction necd irot bc completed if the permit is for onc hundred dattara (SI00)
or Icss.)
I cenify thnt in thc performancc af ihc work (or which �his permit is issucd. I shall not
employ any person in my manner so ss�y bccome wbirst to/� Wp� Compenuuon
Laws of Cslifomia Datc `�� ��- � • / l / �Z
Applicant
NOTICE TO APPLICAM: lf, aftcr making ihis Ccrtilicatc of Excmption, you shoulJ
become subjcct to thc Worlccr'a Compensatian provisions of ihc Labor Codc, you must
, ,� forthwith comply with such provisions w this pecmit shall 6c dccmcd awokcd.
Z O CONSTRUGTION LENDING AGENCY
(.~.� � 1 hereby a[firtn tlut ihcre ia a consuuction Icnding agcncy for thc per[armance of -
p( ✓ ihe work for which ihis permit is issucd (Scc. 3097. Civ. C.) ,
W Q Lendcrs Namc
� z Lende�s Address
I cenify Ihat ] have rcad this application and siatc that U�c a6ovc infortnauun is
�� cortcn. 1 a6ra w comply with all ciry and counry ordinances and sute Iaws relaGng w
0 U building consuuction, and hc�eby wthorin reprcsentadvcs of U�is city to cntcr upon tAc
� W alwvc-mcntiorrcd pmperty tor inspcnion purpos�s
a (Wc) agme to save, indcmnify and kecp harmless ihe Ciry of Cupcnino against
�„H,� � liabilitiea, judgmcn�s, cos�a and expenses which may in any way uccuc against said City
V z in consequcnce of Ure granang oC ihis permiL Date
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO1NT Issued by:
SOURCE REGULATIONS.
� � (�3� Re-roofs
Signuure of Appliant/Contractor � Type of F.00f
HAZARDOUS MATERIALS DISCLOSURE
wll lhc applicant or futurc building occupant storc or handlc haiardous mamrisl
'efincd by the Cupertino Municipal Codc. Chap�cr 9.12, and the Health and Safcty
�, Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs ❑ No
If a roof : s installed without first obtaining an inspection, I agree to remove
wll the applicant or futurc building accupant use equipment or Jevices which •
emit harardous air conuminanu az dcGncd by the Bay Arca Air Quality Managcmcnt all new R iaterials for inspeczion.
a���n
Q Ycs � Nu
1 havc rcad �he hvardous ma�crials requiremcn�s unJer Chap�er 6.95 of �c Califor-
nia Hcalih & Safcty Codc, Sections 25505, 25533 aru125534.1 undcrsiand ihat iCdu bof�d�aB
ciocs not curtently havc a icnan4 ��� �s my maponsibili�y w notify thc occup of thc
requiremen�s wnich musi be 'or w iss a Ccniricaic o� 1 �• � gignature of Applicant Date
pa � . All roof coverings to be Class "B" or better
Owncr or authari�cd agcn�