01110023 (2) OF CUPE
C'BBUILDI NG DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21175/21177 GARDENA DR WISIT VONGAMPAI 01110023
OWNER'S NAME: APPLICATION SUB DATE
WISIT VONGAMPAI 11/05/2001
))� HONE: SANITARY NO. CONTROL NO.
q4
ARCHITEC 'ENGINEER: BUILDING PERMIT INFO
d& FF BLDG ELECT PLUMB MUCH
i 6 I__• LI I_"_ u
It-- LICENSED CONTRACTOR'S DECLARATION
i = 1 hereby affirm that 1 oro licensed under provisions of chapel (commencing Job Description
;why with Section]000)ofDivision]ofthe Business and Professions Code.poli my license GAS LINE.
is in full force and effect.
i O V
License Claws Lic.p
Date Contractor
1 u3_.O Ie ARCHITECT'S DECLARATION
4 1 understand my plans shall M re
used as public cords
:�j f
Licensed Professional
o OWNEc.c. m fn
DER DECLARATION
I hereby effimt that 1exempt frothe Comctnr's License Law for the
wi /
C Z a follong reason.(Section 71O1.,a Lm Business andio Ctde:Any city nr county
_f S 0 which requires a permit m consumer,oiler,improve,ve,demolish,
sh,or repair any structure
S.3$ -prior toiuissuawe.alw requiees theapppplicw
that bili,icensed pinsanuothi pro`dsiomo(Ne Con..&.License law(Chelaef9 C sp�w• �,t,, Valuation
(commRhe encing with Section 7")of Division 3. Buff yy a�Prpfm �tsiuns Code) C�tr.`;? 3 2 �'Qvp y IT v 41_y}-1, 1;
of that be ie eiemptihemfn,m and the basis for the alliged rAemption.Any violation
-
of Section 7031:5 by any applicant for a permit subjects the applicant to a civil'Penalty
of not more than five handled donan($5om. 202APN tNJRRFLOOR PLBING' Occupancy Type
❑1,as owner of Ne property,or my employers with wages as their sole compensation, B
-win-nesse Pro end thedraco is ctor's Li sense Lo.for saleesa., ppy 1.44,- 502 — FINAL PIR PffiN41sPb1RRGY : `iF
,.ill d 't and Professions Code:The Contractor's License Lew does not apply t0 on
owner of property Who builds or improves thereon,and who does such work himself 506 - GAS TEST
or th t u h his o ply provided that such improvements of intended or
-joB dor sale'If,however.the budding or improvement n Id'wnhin'one year of "SO7 - FINAL PLUMBING'-`'". .
c6 pl son,the owns-budder will have the burden of proving that he did not build or
improve for purpose of sale.).
_ _._.ownper _tinges .._.,_-.cont__, ._ .. __.__._.__._cont .. _.__......_.....__..__..._......._......._.... ......._ _
as owner mthe property.71 um exclusively contracting with licensed Contractor's to
consumer the prosect(Sec. to a Business and Professions Colic)impTberoves
ves tat neon, {
_ License Law docs not apply man owner of property who solids se improves thereon,
- _Caron o Livens for.such proiecn with a.camrumr(sl licenud.punumt�m.the
t _
_ comnnoraLeenm Law. .. .
01 coca
pt and Sec. t ';B&P O.(or this reason - tow.�'ifi til
_ Owner��(ly�fy�LJ�L/�f
_ / - ""' WORKER S - SATION DECLARATION
17"? Ihereb ffirmander
y a penalty of perjury one of the following declarations:
. .e .. .
7 I have...'will'inamted a rCby Se tin Consent t selfLubmar for Worker's
Compensation, as ors fol for by Section 3]00 of the•Lebor Code, for the
performnnce of ihi work fpcwhich this pennil is issued.,,
❑1 baud send will maintain Worker
's compenkatiofi lasurdnce,monitored by,Section
3700 of the Labor Code;for the pin rmence of the work.for which this permit is
c. .ask ed MY Workers Compensation Iw -'er and Policy morrinfliger ase.
J s-. t cont.-... .. -..
No
forte
C'i Int t CERTIIICA7 ION OF.EXEMPTION FROM ORK�N ERS,'c— "" -I�s 1 +`�•..T1 ` �,. lw" :' �IL .I I..Srt'ac s ,. �u• 1j
flsssentan need nm be tom laWNf the
FE, one hundred. YL
i r p ' Permit dollars
F..
-(S1W)or leas.)
ITt ilfy that in ih performance of the k f Which thisp mI s issued l
shall n t eimploy any Person to any manner a s to become
Comps 63en t the'Workers - -
cnsauonLawsofCahforom.Data " '
.:Applies.;-'-"`- '..: .. ... ... .. ..__..._.. ..__.__... -
. cont.•_ .,_ _._..into op ho
NOTIC
bemi iTO APPLICANT;aWalk If;Compeafter nsation
this Cdnificate of e Labor io Code.yi;. ail `' u` s•
Z becom h comp y the inch pb Compenmunn provntons of a ihou ! you must.
revoked.
... _....._._s i.. __ ... ......_..
,Z. on t e m y w t sec r t tons o th s alma shall be deemed
F r -. CONSTRUCTION NO AGENCY
I
hihb'y:(firm that th rs a can' lending ergency f i Ne performance
Ne work lbr which th s patron is issued(Ser. Civ.C) '
Lender's Name-
fork ..•.,..
Add': .>"
toiler
1 centfy that I h teed this applic t d stain thvnho oho f rmation is
entree: 1.Hasse of comely'n' all
all.ciry.and my darromesand,tt Is
mlatin8 —
' 0'V mbuldingc.batmctmn and hereby e."..'a represe proves of Iselymsono upon
abovemmaionepey pec Purposes._,
(� W I We)agree In s
an'
indemnify and keep If
the City'of Cupertino against
F h liab 1 u a judg eon, i d xpe_nFes wh ch y n any y etc g inert said
Ciry - q nee hf"a
h gm t ngg of IM1 rat t '
APP TCAs UNDER$TAND$AND LE COMPLY N'1t ALL NON
�POINT - - - - -- - - -- - -
so E AT 1s - •�Q ' Issued by:
Srgn ufApPlcanoCon,rutr:„'�: -.,.,Data' -Re-roofs Date
D
�HA7ARDOUS RIALS DISCLOSURE - "�
III the applies t o future g occupant store r ha die h"66.m retial ,,Type of Roof,
asdfl ad by theCpen.o unicipall Code,Chapter 9.12.and the Health andHfty
liable:❑ on Ys 25532(¢) t Na❑'No i, w ......
,,.,T ,.: -_._All.roofs-shall be.inspected prior.to,any-roofing.material being,installed. _ cont
ill the eppherIpr(uturt building accupentuucquipment ordevicea which If a roof is insialled without first obtaining an inspection;Pagree'to remove
emit If o a omam nen¢ss d fined by the Be,Area A.Quality Management
Dist toall new,materials for inspection. 'Applicant understands and will comply with
❑v. ., oNo. ;i 1 all non-point source reguplations'
P.
rcad'tha harberdpusarman s mgatremeati under Chapter 6.95 of the
Cabfomia Health&Snfny Code;Sections 2550k25333 ertd 25534:1 mderstend that
if Ne builging does not cun0y have.,about,bit it is my issuance
m notify the
acupani of th rcgpir m riet hick must M t prior m les enc fa Cenificem of '
r , --eC
Signature.9--_pplican
_ t .- _ _ - _ _. Date
w r emhonz d¢gem "'
Data, All roof coverings to be Class"B”or better
._'OFFICE... . ._ .. . .. .. ._ ._ _ .. .. onto._ ..cont. . -. _.......__. _
_-