05010103 CI'ry OF CUPEWrINO �.
BUILDING DIVISION PI RMI? CONTRACT R INFl71 2MATIQN� ,
BUILDING ADDRESS: PERMIT NO0 C,010103
1026 BEARDON DR
NF.R'S NAME: PERMIT ISSUE DATE
ELIZABETH CHIN & CHINN CHI 01/18/2005
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±ori LICENSED CONTRACTOR'S DECLARATION
e�� I hereby affirm that l am licensed under provisions or Chapter 9(commencing lob Description
'Qui with Section 7")or Division 3 of the Business and Pioresidens Code.and my license is
±..„ mmumrteawerren. REVISION- -IN HOUSE USE ONLY
>gz
License Class Lica
Date Contractor NO NEW PERMIT ISSEUD/ ORIG. #04110169
�Fp
££ ARCHITECTS DECLARATION
f C< I understand my plans shell be used as public recardt
Tau
o G Liccnud Pmfcssional
7 g OW NEmexemDER DECLARATION Contractors
2 a 1 naso .(Sete thin I am exempt from me Conon Code:Any c Law far the
o O following requires
(Scion Zan LA Business and Professions demolish.OAny city or county
is to which its
anpermit Or construct, Sat fors. Permtme a sig anyam<mre _
°iy poor to its issuance.also rrquimnhe applicant for such Permit hie aligned atammem
< that he is licensed pursuant Lu the Provisions Orrin Commicour's License Law(Chapter 9 Sq.F[. Floor Area Valuation $0
(commencing with Section 70K)Of Division 3 of the B uom.a,and Professions Code)or
that he is exempt mrrtfrom and dm basis for the alleged exemption.Any violation of
Section 7071.5 by any applicant fon permit subjects rise applicant to a civil penalty,of APN Number Occupancy Type
not mare man five hundred dollars(S!50().
32633013 . 00
❑I,ss owner or the prepeny,or my employees with wages.their sole compensation,
will do the work,and me swcture is not intended or offered for sale 7044,Business Required Inspections
and Professions Code:The Co raterr's License Law dots at apply to ea owner of q P
property who builds or impraves thcrean.and who dons such work himself orthmugh his
own employees,provided that uch improvements we not intended or offered for Sale.If.
however.me building or improvement is sold within one year of completion.are owner
builder will have the burden of proving that he did not build or improve far purpose of
ale.).
❑I.as owner of the pec.70s .B exclusively crowning with:)The C ronaanors i-
construct Law does
es not (Sec.n aa.Business and Profusions Cotler)The Contractor's an owner
whocontractsLaces for such project with o conmaetor(s)licensed pursuant m the Contractors SS
License law.
❑Iain canto
(yu`ndcr^Sec. _ .Bh PCfor this Mason \,
net \_" �-'� Dam (— v
WORKS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of me following dcclaralirins:
I have and will maintain aCenihente of Comenua self-insure for Worker'sCompen-
satiaq.provided for by Section I7fK1 Of the labor Cwe,for ric Fcr(oamancc of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation insurance,as required by Section
3700 of me labor Cade,far the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
(This taction need not be completed if rbe Permit is for one hundred dolh¢(lIIX)
or lees.)
1 ckr ifv that in the performance of me work for which this Permit is issued.I shall not
employ any person in any manner anis m bcpome jbjWtu lbe Wartefs''Compcn inti n
La of Calico .Date I
Applicant '` t `
NOTICE TO A�M.I f.after making this Ceniri of Exemption,you should
became subject to the Worked Compensation provisions of the Labor Cwc,you must
D z foMwilh comply with such provisions or this Permit shall be deemed Invoked.
zO CONSTRUCTION LENDING AGENCY
I hemhy aTom that there is a construction lending grey lot the performance of
1S 7 the work fur which this permit is issued(Sec.300)7,Civ.C.)
17 CLender's Name
1 Under's Address
D
J O 1 eerily mat I have and this application and state that the above information is
y F collect.1 agree 10 comply with all city and county ordinances and stare laws relating to
J V building conswction.and hereby authorize representatives of this city to enter upon me
r d .have mentioned pmterty far moratoria Imporea -
(We)agree to save,indemnify and knep harmless me City of Cupertino against
h liabilities,im,nimmus,costs and e,romea which may in any way.cane against and City
..)z in consequence of the granting of this FermiL
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EGULATIONS.
�( fp Re-roofs
Signature of pplican onvacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building Occupant store or handle hanrdous material
as dEred by the Cupertino Municipal Cole Chapter,9.12.and,be Health and Safety
Code,section zss3z(o? All roofs shall be inspected prior to an roofing material beim installed.
❑yea - Nr P P Y g g
Will me itl,bcant or future building occupant uucyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
n emit havardous air conmminanu u cfned by dm Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
Iheve mctyC h,Sccd mamria,25533remn55M.S rChapted6 aifthe Wilding
Tia HealthXSafcty Cak,Sections 25NI5.25slJ and 25534.1 understand thaif the building
dou nos cumcwy haw a remain.mm it is my inalienability to notify tormentor,or me
rtyvirc techsurabeme,Poortoissnao«ofaCrrdOcateserOccupancy. Signature ofAppu ant Date,All roof coverings to be Class"B"or better
Owncr ser authoriacd ad Dam