04120136 C[TY OF CUPERTINO _ a� " ''+
BUILDING DIVISION • PERMIT. COiT " Q T1VOIZMA' ®NF - - ,-
ca .�4 —
BUIIDINC ADDRESS. PERMIT N00 412 013 6
10210 V
OWNER'S NAME: PERMIT ISSUE DATE
QIN PAN 12 /17/9,004
SANITARY N0, CONTROL NO.
ARCHIIECDENGINEER: - BUILDINGPERMITINFO
- -' BLDG ELECT PLUMB MECH
�rs00LICENSED CONTRACTOR'S DECLARATION - Description
(y '.I hereby Mims Nn de
1 am licensed under Provisions of CWpser 9(commencing Job DCSCTI_ p •
with Section 78Division 3 of Busimsa and Pro
10)of D (essiom e.anmy Codd license is
�_❑❑ in m0fomnndeQea ADD 441: SQ. FT. (MS 'SEDRM/DEN) REMODEL
License Clan IX.g
Dam r
mmeter
o
ARCHITECTS DECLARATION
_ 1 understand my plane Mall W insist u public rtemdt
Licensed ProfessionalOWNER-BUILDER DECLARATION
'
Ka
I berohy.(Sermon i am,flush from Ude Contractors Lircnse y areas the
ypo whichpolhov
a permit
t 7fon Suct.al u and Prome.de oli h.or Any oily aMpummm -
$ which mquisea•pump m tai mVa a1.,impmse,demolish.or e 4 sig ed urodum - /J I -
�n
poor to its issnsed PUroroquim the
ovildoscrime anumusch e to cileuigm(shapterl
z�Fp<
that beiatieensed pSadnttal )ofDwan.3afthe minwaldn:eLaw nfonsCepm 9 Sq.F[.Floor Area �f Valuation:
3$ (mmmcncingwith Sectiun70W)M basis n3 nftunegod!era pion.Any vi Code)ar _ �O�`/ `�oO!- _ ---
3
Most he b eaempl thelefmm send Ne bub fu Ne ellryrd eumptlon.Any violation of !/ 7
Section 7031.5 by any applicant fora permit objects the applicant to a dsdl penalty of - r '\:l
mo mom thin flue hundred dollars(M). - e0 G( / 0:q'1 p Occupancy Type
❑Luown"ofthe property,wmy employees with soapsutisk role cmnpennad., ' ��/�I1!//�'�� -,
will do the work and due awccon is ret intended in offered for We(Sec.7049,BW... U ( d.,– - .•„ ,. -
and Professions Code:Thm
e Coacdos tor's I.I.Law not apply to m awns or or '' - Required Inspections ,... -
Property who Wilds uimprommarmse.and who does such work himulfor through his --
Ownemployees.provided that uch improvemeral notimemed woffered foraele.K.. - ..
however.the buildingar improvement is sold within one year of completion,the owns• Y
builds will have the Wr4n of proving that he tlld not build or improve for Purpose of
❑1.an owrcr of the property,am exclusively contracting with licensed contractors in -
construct the project(Sec.70aa,Business and Prorevioce Cade)The course rk U.
Beme law does notapply tom owner of proputywbe bokisorimproses Nero.,and,
who contracts for such projectawith a eommictor(a)licensed pursuant to the Contractor's -
License Law.
1 see p du See .B@PC for thsrecon . .
O V K S COMPENS ON •CL ATION
I hereby affirm order poorly of perjury one of to following declarations:
Ihamantl will msinWnaCerdfdateof Cunumtoself-Insumfor WorkwaCompcn- „..-
nation.u provided for by Section 3700 of the Labor Cade,for the perforenadc of the
work for which this permit Is issued.
❑1 have good will maintain WwkcYs Compensation Imuran¢,u required by Section . .
3700 of the Labor Code,for the performmceofthe work for which this permit is Weed.
My Woraces Compensation Iwnnce artier and Policy number am: ..
Caller. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -(TIM, it.need nod uncompleted if the permit is fororc hundmdda1lan(5100) _
in less)
1 certify that in the performance of the work for which this permit Is issued,l Mall not
employ any .on in my manrcrro u to become mbjectto im Wer cis Compewdon d
Lawn of Califomla.Dam -
Applicant
NOTICE TO APPLICAN.IL after making this Goodman:of Exemption,you Mould -
become subject to the Worker's Compcwtion provisions of se labor Code,you most
.J O forthwith comply with such provisions or this permit shall be dermed rtwnknd. +
'Z ”' CONSTRUCTION LENDING AGENCY
t"4 1 humby alRrm that Nes is a construction lorn ing agency fns the performance or
lYi? the work for which this permit is issued(See 3097,Civ.C.)
Q Lendeh Name
r7. LeadeYa Addmas
U O I=try that I haw road this application and auto that the above information Is
ty Correa.1 agree to comply with all city and county on inances and auto laws relating to
C building construction.and hereby author=representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
D., (We)agme to save,indemnify and keep harmless the City of Cupertino against
y
liabilities judgments,costs and eapemea which may In my wry accrue against and City
in
of ft
U APPnseANTCUN UNDERSTANDS AND this
WILLWWILL COMPLY WITH ALL NON-POINT Issued by: - Date
SO REGULATIO
�u i 12I1� I "WIF Re-roofs
si r licanVCormicmr am
HAZARDOUS MATERIALS DISCLOR Type of Roof
Will deapplic.torfummbuildingaccupanummw tohmudous maerial
as,de0ned by the CupertiWulb..,ld.Ing
Mindenotle,Chapter 9.11.and thq Heals antl Safety
ode,Seetian us31(a)7 All roofs shall be inspected prior to any roofing material being ' stalled.
❑Ys
Will the applicam occupant use equipment or devima which If a roof is installed without first obtaining an inspection,I agree to remove-
It smrdms shin m ed by the Bay Am Air Quality Management all new materials for inspection.
biers
o ves
1 have mad the hmaddnus materials requirements underChalw r6.95 of the Califor.
ria Hcalth SafctyCode,Sa7iom1550S.15333 and 29334,IondcrB.d thuifdte Wilding
does not y haw a Tenant Nat it is my mspomibility m notify the upmt of the
Me hichmus met pnimu,Na ooraCeniOamoftkc Signature of Applicant Date
Owners goo c agcol rte
All roof coverings to be Class++B"or better