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CITY OF CUPERTINO
BUILDING DIVISION PE MAL � 3 C'9I�IN��I�I A ®1�1'
BUIL PERMIT N0.
gD ES 6REENLEAF DR TBD TO BE DETERMINED 07030119
OWNER'S NAME: PERMTTISSUE DATE
WILLIE LU 05/02/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION
t-- 1 hereby affirm that I am licensed Description
13
nscd under provisions of Chapter 9(commencing
U with Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMOLITION
m
L.C..f Clc rind cfG 4�e Lic.#1 Z T 7
Contractor C 4040 NEED CONTRACTOR INFO
ARCHITECT'S DECLARATION
—� 1 understand my plans shall be used as public records
U
U
�-' Licensed Professional
< OWNER-BUILDER DECLARATION
� 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
0 following mason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
y 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 Sq.Ft. Floor AreaValuation
$10000 m
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or 1 0 0 0 0
.. 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 Q,� Number Occupancy Type
not more than five hundred dollars($500). 32630173 ,i�
M 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 forsale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or thmugh his
own employees,provided that such improvements are not intended or offered for sale.IL
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors U.
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such pmjects with a contractor(s)licensed pursuant to the Contractors
License Law.
0 I am exempt under Sec ,B&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-insum 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.
Q 1 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 WorkeesrC7o►mpensation Insurance`carrier and Policy numb
Cartier. O{r}�G F9 A O"' Policy No.: V•`r
CERTIFICATE OF EXEMPTION FROM WO HERS'
COMPENSA77ON INSURANCE )
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I cenify 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
z forthwith comply with such provisions or this permit shall be deemed revoked.
0
C4 CONSTRUCTION LENDING AGENCY
r� I hereby affirm that there is a construction lending agency ror the performance of
7 the work for which this permit is issued(See.3097,Civ.C-)
r-i Lender's Name
Z Lender's Address ,
Q 1 certify that 1 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
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
C/1 liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in cone uenee of the granting of this permit.
APP A UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S RCE GULATi S.
Re-roofs
ignature of Appficant tractor Date t
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0Yes Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmil hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? _
❑Yrs \❑Ffu
I have mad the hazardous materials requirements undcrChapLer 6.95 of the Cali for-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements whit met prior to iss cc aCe tc fOccupancy- Signature of Applicant Date
Owner or u tzcd agent Kate
All roof coverings to be Class "B" or better
CITY OF CUPERTIP
1 �.�, DEMO
I
CUPEkTwo PERMIT APPLICATION FORM
APN# Date:
r
Building Address:
Owner's Name: Phone#:
3 0
Contractor: License #:
Contact: Phone #:
Applicant/Contractor:
Bu' Permit Info: -
ld Elect =Plumb ech
escription-
Residential: l L o _Q16/" C,v S Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer Valuat' n:
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG