04060256 (2) CITY OF CUPERTINOslit *" `•`f
BUILDING DIVISION PERMIT -CCNTI2ACTOR INFO MATION "-
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BUILDINGADDRESS: SP HOME IMPROVEMENT PERMIT"04060256
19711 DRAKE
,S OWNER'S NAME: PERMIT ISSUE DATE
DEREK CHEN 1030 WINDSQR ST
E:
SANITARY NO. CONTROL NO.
(408) 777-8918
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
app LICENSED CONTRACTOR'SDECLARATION IbDIIOn
F I remit,reby affirm that 1 am licensed under provisions of Chapter 9(commencOI'.SCIIP
ing
O with Scat 9 )of Division Sal NC Buxirraa profession,Codc.and mylicensc is
^_cu`, inmllfnr[ Idef [t. REVISION--CEILING BEAM
D&I? Liccnau Li
Zt,w Da - - Cmdo"'a NO NEW PERMIT ISSUED/ ORIG. 404060256
ARCHITEC'SD RA ON
I< I understand my plans shall lit used as public records
JyU
;aG Licensed Professional
3 OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from Ne Comnemr's License Law for the
00 fallowing mason.(Section 7031.5,Business and Professions Code:Any city or county
a E' which require a permit to construct.alar,Improve,demorsM1,nr repair any awnu, _
prior in its issuance.also requires the applicant for such Permit to file a signed sutement
that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valu$tgo9000
pFa (commencing with Section 7000)of Division of the Business and Professions Code)or
i quit he is exempt therefrom and the baso for the alleged exemption.Any violation of
Section 7051.5 by any applicantfor a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mare Nan five hundred dollars($50().
❑I,azownerof the ryopeny.or my employtm with wageaztheh sole compewtion, 31632035 . 00
will do she work and do"Ir mem is not intended or offered for sale(See.7044,Business
and Professions Code:The Contractor.License Law does not apply m an ower of ... Required Inspections
property who buildsm improves thereon,and who doessuch warkhimself or thmugh his
own employees,provided that such improvements art not intended oroRefed for cmc If,
however.the building or improvement is sold within one yes of completion,the i w ur-
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
0 1,az owner of tie pmpcny,am exclusively contracting with licensed ro...1. C+
common the pmjca(Sec.70,14.Business and Professions Code:)The Contractor's Li V
came law does not apply to an owner of purp[ny who builds or improve thereon,and p
who contracts for such projects with a cantnemm(s)licensed pursuant to Use Commchah �I
License law. \
❑I an exempt under Sec. ,B&P C for this reason sem\
Owner Dem \) -
WORKER'S COMPENSATION DECLAQ"
1 hereby difrm under penalty of perjury one of the fallowing declamions:
have and will maintain a CerUfcate o(Comenuo self-insure for Worker's Comped.
on,az provided for by Section 3700 of the labor Code,for the perfonnamtce of the
work for which this permit is issued.
I how add will maintain Warkch ura
Compensation Insurance.as refused by Section
]700 of the labor Code.for Ne performance of the wad for which this permit is named.
Workefs Compensation Insurance carrier and Policy,number ace
cr. SYXITr &[ytlED Policy mea
CEb TIFICATE OF EXEMPTION F MWORKERS'
COMPENSATION INSURANCE
(This auction need not becompleted!fine Pmrit is for one hundred dollars(Shlab
or les.)
I certify that in the perfunnance of the worst for which this Pct u,u issued.I shall nut
employ any person in any manner an az to become subject to the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Cenifmine of Eacmption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.JO forthwith comply with such provisions or this Perm it shall be deemed mvoked.
Z CONSTRUCTION LENDING AGENCY
(-. I hereby OMM Nat Nerc is a eonsvuninn lending agency for the Polio mancc of
athe work for which Nu permit is issued(Sec.3097,Civ.C.)
Q lender's Name
0.
U Z Iermtea Address -
U 0 1 certify Nat I have read the appliemion and stood that the ahove information is
"PconeeL I agree to comply with all city and county ordinances and sate laws relating to
U building construction.and hereby iuthorrre mideam edea of this city to enter upon the
abovcmcationed property for impaction purposes.
gy (We)agree to save,indemnify and keep harmless the City of Cupcnino against
F" co) liabilities,judgmcna.coca and expenses which may in any way scene against said City
U Z in consequence of the granting of this pemnit. /
^ APPLICANT UNDERSTAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURS.
Mad'- & zaRe-roofs
SLgnauunk of A am/ n or Date
HAZARD US MATERIALS DISCLOSU E' Type of Roof
Will the applicant or future building activism store or handle hmardous material
as defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
cod[.Suction zss72(a)T All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes No P P Y g g
Will the appliant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I
hanrdous air contaminants as defined by me Bay Area Air Quality Management all new materials for inspection.
hitt?
t7Ycs XN.
I have mail me haamdms maarials onforemcm under Chapter 6.95 of the Califon
ma Hcalm&Sat2ty Code,sections 25X)5,25537 and 255}4.1 understood mat if Oc Imilding
does not currently haw a tenant,that it 4 my rcsporibility to nobly the occupant of the
requiremdn ' hmu spoor wissuance cur a certificate of Occupancy. Signature of Applicant Date
0 n a�at ori,<a g rat Date �� All roof coverings to be Class "B" or better