05040155 CITY OF CUPERTINO #±v�« a `lRb"�,¢ '" *- "''•' "
BUILDING DIVISION PERMIT i6'C SNTRAACTORIN�b'ItMATIO-,N .
BUILDING ADDRESS: PERMff NO.05040155 5040155
R'S NAME: PERMIT ISSUE DATE
ANDREW KO
E; SANITARY NO. CONTROL NO..
b. !SCf/FNGINEFR: BUILDING PERMIT INFO
2 . BLDO ELECT PLUMB MECH
3Oo
LICENSED CON7sACiOWSDECLARATION Job Description
1 hereby aRirm that 1,m licensed under pmvisks.of Chapmr 9(mmmeocinj
with Section 7IXk)of Division 3 of Ne Business and Profession Code.and my licenm is
+� infbllforccandeffect. SFDWL-2 STORY (3801 ' . LIVING)
?g? Liccnsc Class Lm.S
1 Dam Conuatwr GARAGE-613 . 5 ' /ENTRY PORCH-400 '
ARCNf1EC1'S DECLARATION
1 understand my plans shall be based As public recorde
5 u
s tad Licensed Professional
OWNER-BUILDER DECLARATION
COO hMaso .(Sec on 1 am exempt from the Contractors :Any c Law to,the
p O following recon. emit I.
1.5,Business and rte.ruium Code:My city Or county
COO
which its dresissu n permit re enr,USA aline improve,demrmit 1 JI repair any one me
ant
_ �,' (.dorso its issuance.else requires the applicant formes Permit flle aeignedastamment
=< Nn he is Emmett!pursuant m is provision of de Comracmr'A Luense law(Chapter 9 Sq.Ft.FiNa Val�4"311-
$ (conmencin{wiNS ..7000)nf DivWon3oflho Businessmd ROfessions Code)Or
�.. thin Ire b exempt thcmfrom and the bash for the alleged exemptm.Any violation of
Section 7031.5 by any applicants for a permit subjects the applicmt m a civil penalty Or APN Num a Occupancy Type
nm more done flue hundred Collars(SSW).
r]I.uawrer of tithe Roperry•ar mY tmploym with wgee as denmle mmpensstion,
34214065M..00
will do the work.and the,wctme la mlimemed orolrered Concede(Sec.7044,Business ed Inspections
Ntl Pedproperty
wh Wilds Catlt:Tne Ca thereer, M whorse Lowores doeuch not apply m,n Owne!0I �� Y
pmpertywn0spro idedtovuch alp nwho doss Socnombed AmsexedUuooihi, Ig �asw ,�
amem,the Wilding
or i prove ant is id within
not lntaMedmoRereA Instants.l(. L e���jv■y
howema the buildinE or Improvement i,old wididn aIle yes of completion,proor the Owner-
.1.). will nave We Wrdm of pmvinE that M tlltl not hallo or Improve for pogaxe of
tau.).
V,u Owner of the property,am exclusively connecting with Imensed continuum 10
construct the project(See.7044.Business and Professions Cade:)The Conmen`3IJ-
cense Law does not appy in An owner of property who Wilds or impmw lemon,and,
who contracts for inch peojeeb with smnuacmr(s)licensed pmsusm be the Contractor',
License law.
❑I are exempt under S .B k P C for this recon
Kcr Dau$0
WORKER'S COMPENSATION DECLARATION -
I hereby alarm under peaWy of perjury one of the following decal Won:
m rob will maintain•Cenifiuu of Consent to self.Wure for WOrkelsCompen-
As provided for by Section 37W of the Labor Cade,for the perf Oman¢of the
rY for which this permO is issued.
Q 1 ban and will maintain Worker's Compensation Insurance,u required by Section
37W of dm Labor Code,for d¢perrarmanceof ie wink for whim this permit tainted.
My Worker's Compensation buunnce urtica and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tub section reed nobecompmmd If the perms IS for.nmdmd dollars(SIM)
of mss.)
I unify that In the performance of the work for which this permit U issued.I aiWl nm
employ any person in my manner. 1 bee me mbjutu the Workeri Compensation
Law ofC Iifomia Can,
Applicant ala v—
NGfICE TO APP C :If,arm,milting is CeNOuu of Exemption,you Should
become subject in the Worker's Compensation provisions of is Labor Code,you most
.JO forthwith comply with such provisions Or this permit 0.11 be deemed rented.
y'= CONS RUCTION LENDING AGENCY
EIherehyarfmm all dem is a construction lending agency for ie performance of
> the work for which this Penn IS issued(Sec.3097.Civ.C.)
Q Lender's Namc
=z Lender's Address
V Q 1 certify that I have reed this application and mm that is.bon information is
Dr !' cartecL 1 agree to comply with all city and county entrances and sou law,resting to
O rU^ building co muction,aM hemby auionse mprrxnutivu of this city to enms upon ie
W ,han-ndmed property for impaction purymea
G (We)agree to save,indemnify and keep nmmless the City of Cupertino against
r.a y liabilities,judgmcnta,costs and eepoun which may In my way access against said City
U 7' In consequence of the Eurim:of this petrels Q J=
'7 APPLICANT UNDER DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -1-
SOURCE REG TI
lx(= <{h/-!) f Re-roofs --
Si{wart ofAppliuRr Dau
HAZA
HAZARDODO US MATERIALSDISCLOSUREsome or
Type of Roof
Will the applicant or future building eecbpmutOm or handle h eardaus mamdai
Reed by Oe CupeNm Municipal Code,Chapter 9.11.and the NesIN and Safety
Smtion 25531(.)1 All roofs shall be inspected prior to any roofing material being installed.
Incer❑Ye, CA
Will the applicant or future building Occupant tare equipment AS devices which If a roof is installed without first obtaining an inspection,I agree to remove
harudous air conumin,nu u defined by the Bay Area Air QuaillY Mansatmenl all new materials for inspection.
let?
❑Yes
I have mW the hvndousmaurialsrequimmenu underChspmr6.93 of de Califor.
s
ml"Safety Cade. 15505,3m55y33rcasedpons23l5h3il4l.ly1 understand!ratify thtehuocelfuthpanbuilding
oilfdithng
ntcwlly
requiMs 1poriawmeeOfacrNreamorampsecy e
Signature Of Applicant Date
Owner Or aathoriecd agent Dam All roof coverings to be Class"B"or better