05110148CITY OF CUPERTINO'n
INF'wORMATION
BUILDING DIVISION PERMIT
zCONTRACUO
BUILDING ADDRESS:
OLIVIA JANG
PERMIT NO. 05110145
19060
D` ERE NAME:
PERMIT ISSUE DATE
OLIVIA JANG
1 060 STEVENS CE FkT.�M
11/221/2n0c;
IN E:
SANRARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG EFCr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Descri [ion
1 hmeby affirm Nat 1 am licensed under provide" of Chapter 9 manna- ml
}
rryt q Si �Y p
won Secu0. 7")ef Division 3 of dm Box. and Proleasie" Cade,aM my license is
in full fame and cffett
DEMO (INTER.
License Clan Lie. N
Dam Contractor
START JOB W�TI�OUT PERMaZT,BPERFEE FEES DOUBLED
ARCHr1EC'S DECLARATION
1 underwnd my shall W used as reeorN
�/
Plans public
��/f /p/
Licensed Pmfcuional
OWNER-BUILDER DECLARATION
I hereby alum that 11..Bumps 1M C License Law my
`� N Cl�
Business an
co
cans Cad,: Any city or county
following reason. (Scetiw 71n I.3. and sloes Co
r
t, m,. improve. d. fi mash any uructom
which a permit re en "weL
nt
for such h peonub,
its isu
prior bitsiensnec, Shane quirumvisioiemtrorswhpermi 'sli "asi gncdsummcm
Applicant
NoelhClalienwit pSecttion TrN,provideio of NChe
- ��
Sq. Ft. Floor Area �,
Valuati$lg 000
the Bwinm and Professions Code) of
xem it Section of Business
bsDivision
that he 4e
Nat ha u exempt rMnrmm and the buts fw the alleged eremptim MY violation of
and
APN Number
Occupancy Type
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of
net mom Nan fin hundred dollars ISM
37507046.00
Q 1, ss mvner of the property, or my employe" with wag" u theirmle eompenu0on,
Required Inspections
will do the work. and the swcmrt is at inmiWed woffeird for sale (Sec. 7614. Business
And Psolcsdons Codc The C.,u ' Lice¢ Law data not apply th an owner of
property who builds or improve Verson, and who does such work himself or through his
owe employees, provided that such improvements amnot intend aroRertdforsam.IL
homwa. the Wilding or impmwem... is to within o" year of mmplcuon. Ne owner.
builder will hate the burden of proving Nat he did not build or improve far purpose of
Axle.).
1. as ow"r of the property. am exclusively ..=do, with li.d,onuazbrs b
construct de project (Sec. 76x4, Business and Profession Cade:) The Conuacwe3 U.
came Law does not apply As an owner of propeny who Wilds or improver Nemon. and
who conuacu far such pmjem with a wmractm(s) lica n ed pursuant b the comomwes
License Law.
Q l am exempt under See ,B &PC for NU mason
net tY` �. Dam
ms_cOMP
WO TION DECLARATION
I hemby ff.. under penalty of perjury one of the following declarmions:
-
1 ham and will mainuio acertiRase Of ConYntb self -insure [arWOrk,/s Campers-
cauan, u Provided for by Section 37M of the Labor Code, far the No.... of the
work for which this permit is issued.
Q I love and will maintain Worker's Compensation huormce, ss required by Section
3700ef the Labor Code. to, the performance ofthe work rat which Nis permit is issued.
'
My Woriee', Co n,multion ldsuunce Cartier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Iris cacti. need rot W completed if the perrait la rme. hundred dollars (2100)
or less)
I ectu(y Not in the performance of Nee wart per which this Permit is issued, l Nall not
employ any person in any mmncrlsoss ty bCcc ambjecua the warcery'Compemuuw
Laws of Cattleman. Da,,��- tf x v /o
NOTICE TO APPLICANT. If. afmr acing mill CenfRcem of Exemption. you should
become subpo in the WmceYa Campe"auon provisions of the Labor Code, you am
'
fonbwith comply with such provisions or Nis Permit shall W dcara d revaccd.
1
i CONSTRUCTION LENDING AGENCY
1 hemby afro that dmm is a.onsaucunn rending agency for Nc pr6una nce of
!
the wvh fur which this permit Is issued (Sce. 3097, Cm C.)
Lender's Name
Lenders Mdreu
1 1 certify that 1 ban mad this applicatiw and sum Nu me aWve information is
corms I agree in comply with all city and cowry cNinsrces and sum laws misting in
Wilding construction, and hereby mmodm repro enuuvos of this city m cnmr upon the
shave- mentioned property for purposes.
expmaon
(We) -9— M save. imbeanlfY alld ]MAP barrel. the City of Caperton. aga ndi
costs and which may in any coy ¢cmc Against said City
incoursexjnce, ofu.
, in consequence of the jranting alibis permit.
alibisesmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
6-R'7' — t 1 �' a �p 5
Re -roofs
Signature of Applican✓Conese, Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will tW applicant or future Wilding occupant atom or handle hausdous mamdal
az deflnod by the Cup calms, Municipal Code. Chapter 9.13. and the Health and Safety
. Scmiw 25331(x)?
QY" ® the
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding otsupant use equipment or devices Mich
If a roof is installed without first obtaining an inspection, I agree to remove
mat hazadeu air contaminants as defined by the Bay Arta Air Quality Management
all new materials for inspection.
Disc Ct?
QYes ®Nu
1 hate mad the ha,mmes mvcrid, l.imments under Chapter 6.95 of Nee Califon
his HCahh& Safety Coda, Secumu 25305, 35533 anal 5534. I wdcrstand then ifthc Wilding
does not Carmody have a mourn. that it is my responsibility to notify the ateupmt of the
recut morms which a. Wmet prism rue. ofa Cenih,am or Occupanry.
Signature of Applicant Date
— 112-
All roof coverings to be Class "B" or better
Owner no auth.rizcd agent Dam'