06010068 CITY OF CUPERTINO � `
BUILDING DIVISION PERMIT WONTRAC OWINFORMATIUON�a,
BUILDING ADDRESS: VICENT WONG PERMITNO.06010068
1049.-A rT4T.-,T4nT.m Air
OWNER'S NAME: PERMIT ISSUE DATE
VICENT WONG 06
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
I� 0 0
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
e('� 1 hereby elErm that 1 am licensed under provko
lons of Chapter 9(rnmmcncing
with S..umn 70OB.f Division Sof the Business..Professions Cade.and my license is
in full
License
meand REMODEL KIT & BATHROOMS (2) , �Q
Z trema Lk.Y
Dam Contractor MINOR STRUCTURAL CHANGES
ARCHnLAR
ECr3 DECLARATION
I undcrsunJmy CW
plans shall as ARreeved+cords
5 Lmcnud Pmfesslnnel
gOWNER-BUILDER DECLARATION '
g<i, 1 hereby affirm that I am exempt from the Convector'+License law for the
following reason.(Sudan 703".Business and Pmfmions Code:My city or county n $ �00
5$ which requires a permit to com uct,alar.Impmw,dCmlllkh.or resw
pair any nure �1`
��2 prior to its issuance.also requires the applicant for mesh permit to file a signed statement
< �UZValU1 S�15000
Nal he isImcnsedpursuant totiwprovisions of the ContractorWcemLaw(Chapter 9 Sq. Ft.Floor Area
zC$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
3..
that he k exempt therefrom and the bask for the alleged exemption.Any violNan of
Section 7031.5 by any Applicant for a permit subje m,the applicant w a civil penalty of ppN Number Occas an'@"
MI more Nen five hundred dollus(3500). P y
❑I.uownuortiiepmpeny,umyemployceswithmMuthevrolcrompcmdon, 32641083 . 00
will do the work,and theaVumum Is not intended n offered foram(Sec.7044,Business
and Professions Code:The Contactor'License Law data not apply 0 in owner of Required Inspections
property who Wilds or Improves thereon,and who doo+uch work himsel(or through his
own employees,provided thatsuh improvements arc not Intended aro0ered for sake IL
however,the building or Improvement is mid within on year orcompletion.the names.
builder wi0 hoe ted burden or pmvins that be did not Mid ae improv fu purpose of
.lent.
R1,as owner of the property.am exclusively conveningec
wwith licensed convtors to
oroct the project(Sec.7044,Business and Profesiluns Code:)The Cumnctor'a Li.
ecce law does not pply to an owner of property who W ilds or improv thereon,and,
who contracts for pmjeme with a coommurr(+)licensed pursuant to the Conuanoe.
Lkcme Law.
❑1 am exempt under Sec. __— B&P C fm this maann
Owner TWO KERSLyi DAO
WORKERS COggPPENSATION DECLARATION
I Mmby anlrm under penalty of perjury one of the following declam0ons:
❑Iltaw anal will far by eCWBnu of domnttoCode,fart Ter Wortebce or she
udon,r Providedhthis
for mi Soden 3700 of do tabor Cade.(m dw Performance of Uk
work for which Nk permit it issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
370D of the Lahr Cade,for tins performance of the work for which this permit in Wiled.
My Worker's Compensation Insurance artier and Policy number art:
Carrier. Pocky No.:
CERTIFICATE OF]EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7Nknce ion need not W completed If tis permit is fmone hundred dollen(3100)
or kat)
I certify that in the performance of the work for which this permit is issued,I Call not
employ any perms in any mannerwu to toes t w theworkewcunpemdon
Law+of Califomia.Dam
/q`9z �
Applicant —'� /
NOTICE TO APPLICANT: mmA ng A CcAfcak of Enemption,you Could
become subject to the Worker's Compensation provisions of the tabu Code.you must
.J O forthwith comply with such provisionor this permit shall W deemed rooked.
d.
,.,
51 CONSTRUCTION LENDING AGENCY
.y., IMreb arnrm that pert iso cmunatinnkMin
F Y g gem to,Ne perrurmence of
the week(or which 444 u.permit k issued(S3097,Cih,Cd
W�Q Lender's theme
]z Lender's Address
U0 1 Modify that 1 haw mad this application and tote that alk Above Information is
LU UcorrtcL I agree Io comply with all City and county oNues
iruand sum laws relatito
ng
O Wilding construction.and hereby audhorim reprtmmtivea of this city in enter upon the
W slaw-mentioned property for impaction purposes.
ad (We)agree to caw,indemnify and keep harenlm the City of Cupertino against
r.a VI liabilities,judgments,costs and expenses which may In any way acme against aid City
O 2 in consequence of the granting of this permit q—
G
h7 APPLICANT UNDERSTANDS AND [ Q
SOURCEREGUL (S 'JLL COMPLY WITH ALL NON-POINT Issued by: Date
'o �.. / �r/oL Re-roofs Q f�.2 .
Signuurt of ApplieanUCn rete Data -
HAZARDOUSM • 'A'SDISCLOSURE Type of Roof
Will the applicant or future building accupanbtort or handle huudous material
As dtMed by the Cupertino Municipal Code,Chapter 9,Ig,and the Health and Safety
cede,Section 25532(4)?
r] �1 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant m cquipmant m devices which If a roof is installed without first obtaining an inspection,I agree to remove
. a haardnus sir contaminants u defined by f Bay Ares Air Quality Management all new materials for inspection.
Dial
❑Yen KN.1 have mad the hmardous material,requirementa under Chapter 6.95 of tic Califoe-
AmHalth@SafctyCode.Sutimu 25505.25533 am125534.l ursimmud ft Bae Wilding
docs not currently hew a knenk Nn It b my na pomibility to anufy,tin oaApam of the
requirtmcntswhich mes pdartokyakeaf,amnaka(atapyay. / Signature of Applicant Date
r� All roof coverings to be Class"B"or better
Owner u orimd egem Dal