05040156 777
CITY OF CUPERTINO '-7T"a ' '�'" ''`
BUILDING DIVISION PERMIT eONT,,RAQTb'R INFORMATION;�``„�'"
BUILDING ADDRESS: PE ""'05040156
1967c; T,A MAR nP
OWNER'S NAME: PERMIT ISSUE DATE
YUET POON
E; SANITARY N0. CONTROL NO.
ARCHIECTYENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 t t� o
300 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
I therebyffi
by arm Nat 1 am licensed under provisions of Chapter 9(Commencing P
with Section 7010)or Division 3 of the Business W Professions Cods.and my license is
^� in full fora and effect. ADD 777 t LIVING RM/STUDY/ENTRY
j n Z License Glut Lh:.Y
e nam Contractor BATHROOM REMODELFI L��
ARCHTfECDECLARATION
I understand my plana shall he used u publicwords
Linseed Pmussimml ++ ��..
OWNER-BUILDER DECLARATION
.� I bemby seal.that 1 am exempt from the Contracture License Law for the MAR
E00 following named,(Section 1 S
un 703 ,Business AR
and Profession Cads:MY city ar county
I f. which equina a Permit m concurrent.alcor.improve,demolish.or repair any someone
=Z Sus prior in its issuance,ale coquina the Applicant for such permit to file a signed statement
< that he is licensed pursuant to the provision of the Contractor's License law(Chapter 9 Sq. Ft.Floor Area N U ^' YS%00
0 (commencing with Section 700G)of Division 3 of On Business and Professions Code)or a Q
$ that W is aacmnfr
pi theam and the bads for the alleged exemption.My violadon of t A
Section 7031.5 by Any applicant for a permit subjects On applicant an a civil penalty of APN Number Occupancy "pe
.at marc than five hundred dollen($500).
01,asownerofNeproperty,army unplaytes with wgau theiremeompemuon, 36910018 . 00
will do the work and the struclum isnotinuededoroRered fonale(Sec.7044,Business Required Inspections
and Profession Code:The Comaclor,Liaee n Law donot apply m e ns an owner aT q P
property who buildaerimproves thereon.andwlm doessuchwarkhim elf or Wough his
own employes,provided Nn such improvemenua m nminended oro02ned forum If.
however,the Wilding or improvement is mid within one yew of comp radon,the matt.
builder will have the burden of proving that he did nut build or improve for purpose of _
sale.).
❑I,as ower of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7014,Business and Professions Cade)The Contractors U.
cense Law does not apply in an owner of pmpeny.who builds at improve therson.and
whocco u tem for such pmjecu with aeonuacmr(U licensed pursuant to the Conoacmh
License Law.
❑l am tempt under Sec. – .B&PCfor Nu non
Owner Data
'S MPENSATION DECLARATION
I herob of under local of perjury an or the following declandens:
1
"AM will mNfiam
dnuin ACeof Consent to self-inswe for WonkeYsCompen-
swion,u provided for by Section 3700 of the Labor Code,for Ne perfonmmce of the
work for which this permit la issued.
❑1 haus and will maintain WorWaY Compensation Insuruta,as required by Section
370Dof the Labor Code,for the performance of the work fm which this Permit is hated.
My Worker's Compensation Insurance carder and Polley number am:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This whomneed not Ncompleted if the permit is for me hundred dollar IS 100)
or Mas)
I certify that in the performance of the work for which this permit is issued,l shill not
employ any person in my man�w>b�b��csb je t tole Wmken'Compenation
Laws of Califoro . te
APPliant f=_— f-17��
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provision of the labra Code,you most t
.,O foMwith complysuch with ch Provision m this Permit shall he domed raked.
.77", CONSTRUCTION LENDING AGENCY
[r 5: Ihenby M.that them is•cmouumm.lendingageary,for the perfannaoeof
Arctic Gi 7 the ank for which Nissuedec
is permit o (S3097,Civ.C.)
W A Undoes Nurse
Z)z Londer Mdnss
U0 I mthly haw 1 haw read this application W state Nu the show Information It
L,E comm I apo in comply with W ordinances W ro
city and county orditte lava mining m
C SV" building conawc0an,and hereby authorine mpreemwivss of this city to noun upon Ne
W ahwe-mentioned property for Inspection purposes
(We)AS.to save.indemnify W keep harmlea the City of Cupertino against
wy rA Iiabilifiesudgmeexpensesan
,eosu and expwhich may in y my sg
ome sinstum City
in U pe
APPLICANTeUNDEof the RSTANDS A1ND WILL COMPLY WITH ALL NON-POINT Issued by: Date o'S
SOURCE REGULA t -7/>O/ Re-roofs
Signwu V uaclor Palo
H RDOUS MATERIALS DISCLOSURE Type of Roof
Will the Applicant or(stun Wilding occupant stmt orhandle hwsmous materisi
As defined by the Cupertino Municipal Code,Chapter 9.11.and On Health and Safety
Code,section 15531(.)7 �s All roofs shall be inspected prior to any roofing material being installed.
[3y. Po
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it baumnus aircanuminanu As de0ad by the Bay Area Air Quality Management all new materials for inspection.
DiAwr'0
❑Yrs 6Nu
Ihoemadthehuamtwsmaurialsmquimmsnumn rChapur6.95ormeCalifor-
niaHolth&SafetyCade,Sodm MM5,25533 W 25534.1 unMnund Nulydte Wilding
don or,ca motly hew a moan N II Is mY msponsibllity a newly On am pant lir pro
ngtwmono which eprioru lssuutec ora CcrtiOceteof Occup y Signature of Applicant Date
Owner 6 �O All roof coverings to be Class"B"or better
r seg I Do v