05030106 CITY OF CUPERTINO
BUILDING DIVISION PERMIT t#C�ONTRACT,OR�INFORMATION '*
BUILDINGADDRESS: ROBIN SUNGn PERMITNO05030I06
OWNER'S NAME: PERMITLSSUEDATE
J
ONE: SANITARY NO. CONTROL NO.
(402) 257-1827
CHIT
7—
CHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTOR'S DECLARATION
w❑ I hereby affirm rent I am licensed under previsions of Chapter 9(commencing Job Description
iW wiCSecoirn]OOU)af Division3of NC Buritmv end Professinm otle,and mylicemcu
a« infull fo=andcffen. y DRYWALL ON GARAGE/REPLACE WINDOWS (2)
License o. y Lie.x
-EDam conema141 '5409V r
ARCHI'IECTSDECLARATION START JOB WITHOUT PERMIT/BPERMFEE FEES DOUBLED
ai rasand my plans shall W used as public records
ed 3LLU
O17, Licensed Professional
OWNER-BUILDER DECLARATION
0 0 1 hereby affirm on I ore exempt from the Contractor'sCram:
License law for the
O O which me moan.Permit
to cn construct.
Business and Professions Code:Any tiny at count,
$ which requires n,conch to cnnsuuct.almc intrnovu,h Permit t ore a sig any rwcwm
F z a anon m its e Hothead pursuant also regoirn tbe applicant for such permit m ieIe,a signed nncmcm
Tsethat
commencingwSectiotothe ofDivimmolthe CommnssaLianmLaw(Chapter ode)or Sq.Ft. Floor Area /('�� - ValuaE n200
,w that ba sexamiCScnions and of Division ofthe
eged Business pt Professions Code)or
y Net Section
u campy therefrem and the aper for the alleged exemption.to Any violation of A
not o mm n five any red dam fora Incsmio subjects the eDInlkanuo a civil Penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(5500).
❑I,momrofNeproprnymmyemployeeswiffi gesmdteumlecompcwdon, 36226038 . 00
willdo C,work.and the structure is not intended or offered forsam(Sec.VOaa,Business 'j'
and Professions Code:The Contractor's License law docs not apply m an owner of /Required Ins{Zectiowns%0
property who wildsor improver slemonand whaducs such workhimselforthnough his V �G
Own ver heruilding or improvement
such improvements win not intendedOrOffaxxlmpletion,Tom ers.own r..
however,he building or improvement is sold within one year ofimp completion,for Ne owe of
builder will have Ce aYN[n of proving Nen he did not build or improve for purpose of Q
ole.). yf y}��
❑has owner of e, pec.70a am exclusively contracting s with licensed emm�emrs m (�O//
cons,La Use prejecs(Sec.Sopa,Business and ry,wh nam Code:)The Contractor's nd
come law docs not apply m an owner of proper(Who wilds or antra thm Centra,and
whams,La . for such prejccu with acomnaor(s)limed pursuant mNe Contractors
License Law.
❑1 am exempt under Sec. .B&P C far Cis moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afnrm under penalty of polio,ane of the following dedaratians:
its mand will maintain a Certificate of Cementto self-insure for Worker's Compact-
n.as Innovated for by Secdon 3]00 of dthC,
m Labor Coda,for e perfarro a,of
k far which Cis permit is issued.
I have and will maintain Workers Compemation Insurance,as required by Section
3900 of Ce Lobar Code.far Ce performance of Ce weak for which this recall is issued.
My Worstri Confirmation Inamorata cannot and Polity number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is forone hundred dollars(5100)
manse.)
I certify that in Ce performance,of the work for which this permit is issued.I sbe1l not
employ any person in any manncrsn as m become subject to the WorkersCompensation
Laws of California.Data
Applicam
NOTICE TO APPLICANT:If,aloe,making this Cenifienm of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you most
.J O forthwith comply with such pravism.or Cr permit shall be deemed revoked.
'z " CONSTRUCTION LENDING AGENCY
[-+� thereby affirm that than is a construction lending agency for the performance of
LLa > the wurk for which this permit is issued(Sec.30YI,Co.C.)
U.1 0 Lender's Name
z Lender'SAddrms
U Q 1 certify Cat 1 have mad this application and me,Nan Cc above infominiun is
D.(.. cormet.l agree to comply with all city and county ordinances and sum laws prating
OrJ building construction,and hereby auismirz¢psmnutives of this city m enm,opnn bac
Y'C above-mcauoned property for impection purpoma
(—' (We,)eCme to ave,indcmmfy and keep harmleu Ce City of Cupertino egaimt
p) liabilities,judgments.costs and ex,emm which may in anyway seers,against said City
U z in conn mnce of Cc gwting of Cis Ntmit.
APPLICANT UND STAN 6At1j)I WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC LONS. �
� 7 0 Re-roofs
Signora.of A,imaso'Conuazmr/ Data
HAZAROOV4 MATERIALS DISCLOSURE Type of Roof
Will Cc applicant or futon building occupant snore or battle hanNous material
u defined by the Cupertino Municipal Code.Chapter 9.12 and the Hadils and Safety
Cale Section 25572(a)? All roofs shall be inspected nor to an roofing material being❑Yea
AN. P P Y g g installed.
Will the ar Mean or future wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haeardous air exi mminanu as defined by Ce Bay Arca Air Quality Management all new materials for inspection.
rict?
❑Yes O(No
1 hav,read the hvardous materials requirements under CWpmf6.95 of the Callfm-
maHcalC&Safuy Code,Sections 15505.25533 ano 2553a.l understand that d ars,Wilding
does an,curroody have a tenant.Nan it is On,reapomibility to notify Ce Occupant of the
re uncorm 'hmustM el Poor it)issuance of a Cc.finmof aur naY. Signature of Applicant Date
® 0' O
toner or authooaed agent Dal, All roof coverings to be Class"B" or better