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BUILDING DIVISION
OWNER'S NAME:
MICHAEL CHEN
ONE:
ARCHITECT/ENGINEER:
PERMIT
CREEK BLVD
LICENSED CONTRAUIUR's Ut:cuutnt tutu
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
rith Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and effect.
License Class Lic.il
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to convect, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars (1500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or imprnves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
D
Owner
Date
S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
j I have and will maintain a Certificate of Consent to self -insure for Worker's Compcn-
,ation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
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PERMIT NO.
MICHAEL
FE MIT 1S5UE DATE
01/10/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
Job Description
REVISION: REPLACING GREASE INTERCEPTOR
ORIGINAIr PERMIT: 06080165
36903006.
] I have and will maintain Worker's Compensation Insurance, as required by Section
1700 of the tabor Code, for the performance of the work for which this permit is issued.
Ay Worker's Compensation Insurance carrier and Policy number arc:
:artier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is for one hundred dollars ($100)
)r less.)
certify that in the performance of the work for which this permit is issued. I shall not
;mploy any person in any manner so as to bceo to W rs' Compen_ 'on
Laws of Cali(omi
Applicant
NOTICE TOA CANT: If, after making this Certificate of Exemption, y should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a convection lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building convection, and hereby authorize representatives of this city to enter upon the
about -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- NT
SOURCE REG ONS. Q
Signature scan tractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes 16 No
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Management
.)istrict?
❑ Yes (t�Nu
have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to fy the occupant of the
reuirements met or to' cc of a Cori a c
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Date
Ft. Floor Area
$92500
Required Inspections
Valuation
Occupancy
Re -roofs (/
Type of Zoof
All roof:; shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signatur,_ of Applicant
All roof coverings to be Class "13' or better
Date