04010103 CITY OF CUPERTINO 9 '',�.I1� $;mss a�' Y'gw
BUILDING DIVISION PERMITON�RA.GT.4R LAlI
BUILDING ADDRESS: - SARATOGA CONSTRUCTION PERMIT ND04010103
10568 SAN LRANDRO AVE.
OWNER'S NAME: PERMIT L`suE DATE
LYNN CHING 12201 SA
E; SANITARY NO. CONTROL NO.
(408) 996-1711 t
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
L o 6 LICENSED CONTRACTOR'S DECLARATION
zd I bmeby 55ffrfrm Net I am Ilcenud under pmvii..WWna of Chapter Y(commencing lob Description
with Sermon 7B00)of Diviaion3of NC eusinmserW FoYmsiona COJc.antl onto is
^ y in full fortes dtffectp 3 SFDWL-ONE STORY W/BASEMENT (18611 )
j Z Ucenu Class Lic.p
cnmraemLIVING 3550 SQ. FT. /GARAGE 510 SQ. FT.
RCHITECI'S DECLARA '
4a I unyrl�sant 1 t s shell W mad u public records
O Licrnu1 Flt man 1
S OWNER-BUILDER DECLARATION
T.<f 1 hereby reaso .(Sta teas 11. tromps from the Contractor'sCod :License Lew far IW
T.0 0 which re mason.(Section](131.5, t,Business and Profdemol Coot:Any city ter cnuure
$9 which requiem a permit m construct,clog imprnw.JcmnlisA or repair any structure
pattern its issuance,alm requires the applicant nonsuch permit to file a signed statement
¢REM that he is licensed runuonuo the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Va 000
1-$ (commencing with Section 7")ofDivision 3 of the Business and Profemions Cute)or 0
ey.- mar W is exempt dletefrom and the basks for the alleged assumption,Any violation of
Section 7031.5 by any applicant for a permit subjema the applicant at a civil penalty of APN Number Q U anC e
nos mom Nan 0w hundred dollen($500). P Y Type
❑i,asawncr of the propcny,mmy cmployceswim wegeam thele role compensation, 35705029 . 00
will do He work,and meswcmm is redinunded oroffered forsalo(Sec.7044,Business Required Inspections
and Pmf be ions Code:The Commutes Liwnu Law does not apply m an owner of q p
property who Wilds;or improves Hereon,end who does such work himsel f or through his
own employess,provided Nus such improvement art not-nanded oroRered for sale.If.
however,the building or imp owmenn is said within one year of completion,the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
salt.).
❑1,as mener of the propcny,am exclusively contracting wit licensed contractors to
construct the project(Sec.7044.Boehm and Professions Code:)The Contractors Li.
tome law Join not apply no an owner of property who Wilds or improves Herten,and.
who conuaca for such projects with a contractor(s)licensed punm n to da Convactor's
License L.
❑I am exempt under Sm. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby of ton under penalty of perjury one of fee following declantionse
haw and will maintain a Certificate of Consent to self-insure for WorkclsCompen-
137M
n,as provided for by Section 3700 of me Labor Code,for are performance of the
for which thin permit is imbed.
have and will maintain Workeh Compensation Insuranw.as required by Section
of NC Labor Carle.for the performnam of the work for which His permit is issued.
Worker's Compensation fmunnce carrier and Policy number art:
e Policy No.: +
CERTIFICATE OF EKEMPnON FROM WO$IEERS' ..
COMPENSATION INS URAN
(Thks sermon need not be completed if the permit is rnronehundred dollus($1,M)
lora) '
1 certify that in me performance of she work for which His permit is issued,l shall not
employ any parent in any member sa as N becomesubject to the Workers'Compensation
Laws of California.Dom
Applicant
NOTICE TO APPLICANT:If,after making this Cdnificaic of Exemption.you should
become subject no the Worems Compensation provisions of the Leber Code,you must
.JO forthwith comply with such previsions or this permit shall be deemed revoked.
,'Zs CONSTRUCTION LENDING AGENCY
[-i (hereby affirm Nat there is a construction lending agency for the performance of
(yi > the work for which oris permit Is issued(Sec.3097,Civ.C.)
tri Q Lender's Name
Z Lender's Address
fJ Q 1 cenify that I haw mad this application act sate that the about information is _
W F correct I agree to comply wife all city and county on-names and sane laws relating to
0U building construction.and hereby authorise representatives of oris city to enter upon the
�G abovamentioned property non inspection purposes.
(We).,me to saw,indemnify and keep harmless the City of Cupertino against
ti,n IiabiliasJudgmena,costs and expenses which may in any way accrue against mid C-ny
U Z in eonuqueneca eBrantI. o permit.
" APPLICANT U Ipm D WILL COMPLY WITH ALL NON-POINT Issued by:S �(&zat
SOURCE REGU ONS
'V 41 Re-roofs
Sig ofd Cunm to Dam
HAZAR OUS ATERIALS DISCLOSUR Type of Roof
W' Nc applicant or larva dJmgamupant stow or handle hverdous motorial
as dt0 d by the Cupertino Me -pal Codc.Chapter 9.12He HcaW and Safely
Code.Section 25532(a)? /
(]lobs In No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or I.
wilding attupam use cyuipmtnl or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
s haaardnus air conumina normal by she Bay Arca Air Quality Management all new materials for Inspection.
iatrict1
❑Yes Nu
I have ma 1se�emrdous materials mquarrountsunder Chapter6.95oftheCalifor-
nitHealH&Sof yCadc,Scctiom25 05r25533anJ75534.1undcntamdmatifmc Wilding
dors not cuneus y he E�E t te L )yu my responsibility m mory the occupant of me
reyuiremcn swl'c nmb a PmissuanecofacenlOmu, f0m,�ap '. Signature of Applicant Date
Owber abme acdagtrt Date All roof coverings to be Class "B"or better