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CITY OF CUPERTINO�'�"v-`,
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BUILDING DIVISION PERMIT
-ONTRAGT( FORMATION .
BUILDING ADDRESS:
CHINGFEN SIM/WEECHEN GAN
PERMIT NO. 06040034
10822 WILLOWBROOK WY
NER'S NAME:
PERMrr ISSUE DATE
CHINGFEN SIM/WEECHEN GAN
04/07/2006
PHONE:
SANITARY NO. CONTROL NO.
ARCHIIECTIENGINEER:
BUILDING PERMIT INFO
BLOG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job DOSCr1pI100
1 hortby affirm WI l am liceaad under porru ons of Chapter 9 (mmmcacing
wish Section 7008) of Division 3 of Ne Business and Profasi^m Code, and my license is
in full Come and effmL
ADDING BATHROOM TO EXISTING SQ. FOOTAGE
Liana Clan tic.9
Dam Cmaracmr
ARCHITECTS DECLARATION
1 undersand my plans shall be used at public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from she Contractors Uecnae Law rat the
following reason. (Section 7101.5, Buioess and Profasduns Cole: My city at county
which requires a Permit to conswcl, alcor, improve, demoliu h. or repair any structure
$3000
prior to its issuance. also requires Be applicant for such rattail o file asignW sutemcm
Contractor's ureas, Law(Chapmr 9
Sq. Ft. Floor Area
Valuation
that ho is licensed purmant to the Provisions of the
(command, with Section 7000) of Division 3 of the Busineaemd Professions Code) ser
: shat he as exempt demf are and the basis for IW alleged .....pts. Any violation of
r
Occupancy Type
Section 7031.5 by any applicants for a permit mbjccu Jte applicant to a civil penalty of
not mart dun five hundred dollars (SSW).
❑ 1, as awns of dos prep Try, or my employees with wage at their sole compensation,
RequireqVirections
will d0 dlt warp. sad dle sWclane Ice mr, intended W offered rot safe (Sec. 7044. Business
and pretense. Cade: The Canbxcmrs License Law, does Out apply to m owmr of
property who builds orimproves Ncrmn, andwhn doessuch work himselforthrough his
awn employees. provided that such improvements are not intended aroRertd rat sale If.
however. the building or improvement u said within ane year of mmplction, the owner-
builder will have the burden or proving NW at did not build at improve for Purpose of
de
,a
�g
/
sage
S�11, as owner of the propeny, am exclusively contracting who licensed contractors to
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construct the project (Sec. 7044, Business and Rofesvans Code:) The Contractors U.
cense Law dors not apply b an ower of property who Wilds or improves thertan, and
who contracts for such pmjecu with a convactor(s) licensed pursuant b the Contactors
License raw.
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❑ I am exempt under See . B A P C for this moon
Date 1 u0
--WORKERS
COMPENSATION DECLARATION
1 hereby Nim under pevlty of perjury ane of Jct following dmlm Gam:
❑ 1 have atW wBl mvntain a Certifiate of Carucns m self -insure far Workers Compen-
sation, u provided far by Section 3700 of the Labor Code. for the Performance of the
work for which Nis parmil is issued.
❑ 1 have wood will maintain Workers Compensation Insurance, as required by Section
3700 of are Labor Colic, Tor Ne performance of the wart for which Nu Permit is issued.
My Workers ComPewtian Insurance artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITusectim need ret as, cmnPkted if Irk pcmis Is leant hundred drBan (5100)
or less.)
I cetufy that in the performance of dm work far whi Nis Permit is issued. I shall nm
emplpy any' pC(aan i0 any mallnet So i{ b bC0];C jypJrl la dM Worktrs' Compensation
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Laws of California. Dam f U
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Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject b the Worker's Compcnsman provisions of dm labor Cade. you most
' forthwith comply with such provinces or this permit rail W lamed revoked.
i CONSTRUCOONLENDING AGENCY
1 hereby affirm WI there u construction knding agexy for dm Performance or
the work fur which thus permit is issued (Sec. 31191, Civ. C.)
s 3
I<ndefs Name
t<nders Add.
I I ratify Nat I have read this appli'm xi and sum than the show, information u
commL 1 agree to comply with all city and county aNinances and sate laws relating to
building construction. and hereby authamc mpresenutiva of this city to enter upon the
stave-menuuned property for inspection purposes.
(We) agree to ave. indemnify and keep harmless the City of Cupcnino against
j liabilities,judgmenu.cosu and expenses which may in any wayaceruc against said City
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in consequence of the granting or this permit.
APPLICANT UNDERSTANDS AND WIL{ COMPLY WITH ALL NON -POINT
SOURCE 1
Issued by:Date
*
REGLILATIIgNs.
—
Re -roofs
Signature of ApplrscaHp Data
ARxmr
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the mpficar,mrfuture building handle anmateriel
u defined ge Coe, Chaptrmreor
dte Cupenina Municipal Code, Chapter 9.12, and the Health and Safety
Health
io
. Section 2ss321a)'
❑Yesgo '.
All roofs shall be inspected prior to any roofing material being installed.
Will thea Iuant or future building accu t ase which
pP g ^ equipmentat
If a roof is installed without first obtainingan inspection, I agree to remove
p
emit havaNnus air contaminants u defined by the Day Area Air Quality Management
e Mann
all new materials for inspection.
District?
❑Ya '12"o
In ave mrd the hanNeusmatenals hequiremcnu underCWpterb.95 or& Califor-
out Health aSdetyCodc, SWUM 255115.25533 and! 25534.1 unArsunA that ifthe Wilding
Jaa not currently hasttenana Nat it u my mspomihilisy b notify dm a,upmt of the
requircmccu whichm Wm mia a,pterfacwfiateoracuyty
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or authoriand agent Data