03010151 CITY OF CUPER'1'INO
BUILDING DIVISION PERMIT CONTRACTO RINFORMATION
BUILDING ADDRESS: CUPERTINO CONSTRUCTION INC PERMIT NO.
22291 JANICE AVE
OWNER'S NAME: 10079 SAICH WAY APPLICATION SUB DATE.
ROGER & JING—LING LOW 01Z27/2003
NE (408) 253-9000 SANITARY NO. CONTROL NO.
ARCHHECUENGINFER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MICR
WOO LICENSED CONTRACTOR'S DECLARATION O O O O
s�F Ifoods,alfrmlhnl lam licensed under pmvixlnnsof Chapter 9 bmmcrom, Job Description
�<i with Section TXXR of Division 3 of the Busiest and PrnfeWons Code.and my license is
�� in mufny'adeffect. 6eif DEMO 448 SQ. FT.
ZO'aG Licca: lavxn -37I,ic�.MaL1p,
O�~',y ARCIIITF.CI'S Ijf;CLARATI N R f NALE®
-sp5�a lunderstand my plans xM1allMuud as public Tett ds
2-L public
Limn.¢dPnrlessiO°°I FEB 12 2003
ImtOWNER-BUILDER DECLARATION
of cep I hereby affirm that I am exempt from the Contractor's License Law for the
w F n O following reason.(Section 7031.5.Business and Professions Code:Any city or county '
x m which requires a Permit tit coostruet
,alar.improve,demolish,or repair any structure
fri to its issoanee.alsooe,mors Ih,.,pllcum for such M.fit to fileasignetlomumem
ss`o that of is licensed purseanttodreprovisions ofdue Contractor,License Law(Chapter 9 Sy. Ft. Floor Area $5N'7DGation
tot- (Commend not with Section TXXA of Division 3 of the Business and Profetdhns Code)or
m W§ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than Bre hundred dollars B$500). Occupancy Type
❑ I,or owner.(,he pmpeny,hr my employees with wages as Neil sole compenSatinn,
will do Ne work,and the structure is not intended or offered for sale(See.7014,Basioeas
and Pmfessum"Code:TM Convectors License law does not apply man owner of equtre nspec Ions
Property who builds or improves thereon.and who drcssuch work himself or through his
own employees,provided that such improvements are not in¢nded or offered for Sale.If.
however,the Wilding or improvement is sold within one year of completion,the mvner-
builder will have tM burden of pawing that he did not Wild or improve for purpose of
salt.).
L as owner of the propeny,am exclusively contracting with licensed contractors to
construct tM pmjeet(Sec.7014.Business and Professions Coded The Contractors Li.
cense law does not apply to an owner of property who Wilds or improves themnn,and
who'smtnea for such pmjecs with a contractor(s)licensed pursuant to the Contractor's
License law.
❑I am exempt under Sec. B a P C for this match
Ownc Date
WORKER'S COMPENSATION DECLARATION
I hereby sff rm under penally of perjury one of the following declarations:
[haw and will maintain a Cenificate ofConsenuo self-inure for Worker's Cumpon-
wtion,as provided for by Sectio 3700 of the Labor Code,her the performance of Nc
work far which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,at required by Section
37011 of Ne labor Cmix.for the performance of she,work for which this permit is issued,
My Worker's Compensation Insurance carrier and Poli' rare:
Camicc Polity N .
CERTIFICATE OF EKEMRr10NFR MWORKF.RS'
COMPIiNSAT10N INSURANCE
rsactionheed notMeomplemdifIMr mitisfnron'hundreddollar(SIIMB
less)
1 c rm y that In theNflorTance of the work for which this Permit Is Issued,I shall not
employany press.irmnner m as to be7e7yt toit S wee Cnmpcaliamn
laws of California.Dr.
P""TCE TO APPLICANT:If, for making this Cen roan,of of Es
e subject to the Worker's Compe asome provisions of IM1e Inbar Cndc,you must
O z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
'r Ihereby affirm drat there is a condmetion lending agency for the performance of
C the work for which this pemol is .sood(Sec.31.77,Civ,C.)
aLener's der's t (�
a z LedAddress
tJ Q 1 aongnify Nat 1 have read Nis application end sum that the aWve information is
W F Correct.lagree to comply with all city and county oninances andsmm laws rending to
Q U building construction.and hereby submirs representatives of this city to enter firm the
aMvemcnudgm properlyst for inspection purpowhich ms.
H 0.i (we)agree m save,indemnify and keep harmless the City of Cupertino against
N liabilities once of the costs and expenses which may in anyway attmc against Said City
U z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
URCE REGDLATION$, � 1✓O
Sgnato Pp 1i'and.......a.."r-,r I are 1' Re-roofs
IIAZARDOU S MA'nBRIALS DISCLOSURE Type of Roof
Will the applicanttar future building eapt store or handle Iheallousmammal
at defined by the Cupeninn Municipal Code,
Chapter 9.12,and IM1e Ilcallh and Solery
Calc,Station 25532(x)'!
❑Yes xNn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Rome Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
lit hatamous air conlaminanls as defined by the Bay Area Air Quality Management all new materials for inspection.
Dimrief!
❑Yes IK No
1 haw read the havardous mmarlal imquimmem un@r Cliap¢r 6.95of Be Califoo-
nia Health 5 Safcty Ct lc,g '6G)ns 25505,25533 and 25534.1 undersand Natif Ne building
thea not currently have a tenant.that ii iv rey responsibility to nodlY floctceuPam of the
m ummcntx which mullM met fin ono' once ofa Cenlucam of 0.euPan Signature of Applicant Dale
1 r7 c
Uvorese,elludhormed agent Dale All roof coverings to be Class "B" or better