04050081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ' ;
BUILDING ADDRESS: MDR NELSON RAMOS PER.....b4-050081
) 0076 CRESCENT RD
IOW NER'S NAME: PERMIT ISSUE DATE-
KEN WOO
E: SANITARY NO. CONTROL NO.
(650) 834-1260
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
S BLDG ELECT PLUMB MECH
u0G LICENSED CONTRACIDR'S DECLARATION O O O
C I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
ZU withsect n7 )of Divislon3of Oc Busir�a�and Profusions Code,and my Lice=is
<a Licenser fid cffxk � �3 REVISION--IN HOUSE USE ONLY
>'q_ uame Cl Lica g
re, Dam SD!l! 110 NEW PERMIT ISSUED/ ORIG. #0310052
Z'y ARCttITELTS DEC A ON J
ala I antlers fid my plans shall W recd arts tic recoNs
JyU
3 G Licensed Profcssionsl
OWNER-BUILDER DECLARATION
.�<i d hereby affirm that 1 em exempt from the Contactors License Law for the
00 following....(Section 7831.5,Business and Professions Code:Any city or county
g ff which requires a pctmit us construct,else,improve.demolish,or repair any indent.
Fieprior m its issuance,also requires the applicant for such Permit o file a signed statement
Nat he is licensed pursuant in the provisions of the Convector's License Law(Chapter 9 Sq.Ft. Floor Area Valuati(p107
(commencing with Section 7")of Division 3 of Ne Business and Profusions Coee)ser
y 2 Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Secdon 7831.5 by any applicant for a permit subjects the applicant to a civil pcnal(y,of APN Number Occupancy Type
mat more Nan five hundred dollar(5500).
❑I,uawtvtrfNe proputy.mmy employas with wages es Ue'v sole campensa8on, 32617036 ' 00
will de,the work end Nesuucture is not intended oroffered forule(See.7044,Business
and Professions Code:The Contractor's License Law does not apply to in owner of Required Inspections
property who builds or improves thereon,and who docs such work himself or through his
own employ=.provided Nat such improvements are not intended oroRemd for sale.If,
however,the building or improvement is sold within one year ofcompleuon,the rwncr-
W ilder will have the burden of proving that he did not build or imp..for purpose of /f
ulcd. \�\
❑h as owner of the Sec.poaporil,.Business uand contracting with:)The,Connuaaors i-
comtrun 4 cut pply to a. me, end Prefixes.Code,:) p..then er's Li- \P
wholaw dose not apply je an owner of prouu(s who Wilds ra improv's Contra,end p
whoaseLcontracts for such Projects with a eonvacmr(s)licensed pursuant m the Contractors
Liccnon law.
❑lam exempt undo Sec. ,B&PCfor this moon
Owner Date
( WOR KER'SCOMPENSATIONDECLARATION
1 Ihertby aRmn under penalty of perjury one of Ne following dedacetiotm:
1 have and will maintain aCcnircam of Cormcm to self-insure for Workerseompem
utirn,as Provided far by Section 37M of the,Labor Code,for the perfrrnamme of the
work for which this permit is issued.
1 hats and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code.for the performance of the work for which this permit is issued,
My Workers Compensation Insurance carrier and Policy number am:
C�( Paltry No.:
, CERTIFICATE OF E%EMPTION FA KERS
✓✓ COMPENSATION INSURANCE
(Thh section need notal contif the permit Is torr.hundred dollars(51IX8
or Rss.)
1 cmufy,On,in Ne perfom voce of the..,it for which this Permit u issued,l shall net
employ any person in any manneran u to hecomc subjecu,the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making Nu Certificate,of Escmption,you should
become subject to the Workers Compewtion precisions of the IaWr Code,you muse
.JO forthwith comply wit such provisions or this Permit shall he deemed revoked.
'z .~N.. CONSTRUCTION LENDING AGENCY
(-+ I hereby affirm that there is a construction lending agency lot the performance of ,
x the work fur which this permit is issued(Sec.3097,Civ.C.)
QLenders Name
z Iendc"sAdtlmss
U 0 1 certify Net I haw read this application and sutc Out the above information is
IL F-' correct.1 agree to comply with all city and counry oNinences and note laws relating to
DU building communion,and hereby authorise mprtamutives of Nis city m cnor upon Ne,
} �, ahowortatimRd property for inspection purywsea
(~gy (We,)agree to save,indemnify and keep harmless the City of Cupertino against
(q liabilitiu,jutlgments.costs and expcnsa which may in any way accme against said City AC
U in consequence of the granting rrthis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WI LL NON-POI Issued by: Date
�SOURC GULADONS. _ 7
2 Re-roofs
naor fApplicanvConlractor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building=Want stare or lotmk hvaArus mamdal
as defined by the Cvpenina Municipal Code,,Chapter 9.12.and the HeaIN and Safety
code,Qy Section 255320t), All roofs shall be inspected prior to any roofing material being installed.
Will the applicant fir future building occupant use waipm=nt fir devices which
If a roof is installed without first obtaining an inspection,I agree to remove
*It hararch us air contaminator as defined by Ne,Bay Arta Air oustily Marmgcmcnt all new materials for inspection.
District? �n/
0Yes An
1 have mad the bavardnus noteruds requimments under Chapho G95 of Ne Califor-
nizHealNkSafetyCode.Secuom 255115,25533"15534.1 understand thmifIhe Wilding
dose not currently have a Rent.that it is my respo,uihility to notify the recupr a of dtc
re,pit cwhichmumbeMCIprinotoea f.CuurnmfirOcapanry Signature of Applicant Date
All roof coverings to be Class "B" or better
OJR6ora orisd agent DaR