06070062CY OF CUPEKfli
BUILDING DIVISION
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BUILDING ADDRESS:
21535 MONROVIA S
OWNER'S NAME:
QUEEN LEE FOO
PHONE:
ARCHITECT/ENGINEER:
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
vilh Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and effect.
.icense Class Lic. A
)ate Contractor
ARCHrmcrS DECLARATION
I understand my plans shall be used as public records
-icensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
'allowing mason. (Section 7031.5, Business and Professions Code: Any city or county
rhich requires a permit to construct, alter, improve, demolish, or repair any structure
irior to its issuance, also requires the applicant for such permit to file a signed statement
hat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
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 ($500).
❑ I, as owner of the property, or my employees with wages as thew sole compensation,
will do the work, and the structure Is not intended or offered for sale (Sec.7044. Business
and Professions Code: The Contractors 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.).
XI, 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 themon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractors
ense Law.
;, I am exempt under Sec.
, B & P C for this � n
er. o;L Own� *sm L� 1i � Date72
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to 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 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 Compensation Insurance carrier and Policy number arc:
Cartier. Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
C0MPENSA'I7ON INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less)
1 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 Califomi
Applicant
NOTICE TO AP CAM: 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
1 hereby affirm that there is a conslruciinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building conswction, and hereby authorize representatives of this city to enter upon the
above-mentiuned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupcnino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTAAN(/[/L/��SS�AND WILL COMPLY WITH ALL NON -POINT
SOUR ULA'p1.0NC^'!/"l 2 f 2" 1
Signatu of Applicant/Contracmr Dam
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)?
❑ Yes 9 No
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 Wo
I have read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & Safety Codc. Sections 25505.25533 and 25534.1 understand Nat if the building
does not cu nfly hatenant, that it is my responsibility to notify the occupant of thc
requircm which ptusi be mnio�r io issuance of a Cenifica of Oc panty.
Owner 7 authorizcd agent Date
E FOO ,
PERMIT No06070062
PERMIT ISSUE DATE
07/12/20O6
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
KITCHEN REMODEL, CABINET REPLACE, NON.STRUCTURA
Sq. Ft. Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
20000
Valuation
Type
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
allnew materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better