01070024 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: Limmi r NO.
11149 SUTHERLAND AV 01070024
DCyryF,rt'S TEI IN S AND YANG JA 0 7 f 110th/SUR
0 01
•, PHOriNEU: SANITARY NO. CONTROLNO.
o s Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
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Z S h z LICENSED CON'nBd ands,S DECLARATION Job Description
O z-o I hereby affirm mat 1 am licenced under provisions of Chapter 9 kommencing 3 BATHRMS REMODEL.
pmt_w with Section 7000)of Division 3 of the Su.sine.szand Professions Cade,and my license
<x f Is In full forte and effort. I V a-)3
z z a Leans CI s Lis p
O Or D Data ��I rk 5 x Ciarmic o�.-s�.� /
ou 3 LL}"., ARCHITECT'S DECLARATION 3 Q
I-a g 1 wdemmd my plans shall be used ex p,,hire recent, /
to 8c Licensed Pwfesslonal
o se OOWNER-BUILDER DECLARATION
'—' I hereby affirm mat 1 am exempt from the Contractor's License law for Ne
F z a following reason.(Section 7031.5.Business and Professions Code:Any city or county $10000
E x 0 which requires a permit to conamct,alter,improve,demolish,or repair any wrucmm
nter3 pn t is suama also req res the appl conifer hpenmtt fk 'good ztatemcnt - ..._ _.
(cto
(commencing with Section
7000)pro(vDisictio:n'.oflNeer Choe Bovide ssL'nJ Pr W6..ons Code)
, .,.,x_1•_.. • ,.• Qor"ea Valuation
.
,
or that he iz exempt therefrom and the basis for the alleged exemption.Any violation
of Scctio,7031.5 by wyappla.rat ku,spermitsubjeers Neappleant modsil penalty
lof not more than eve hundred dollars 15500101ABN$ ATION Occupancy Type
°I,a.s owner of the pwpery,or my employees with wages a,theirwle compensation. 102 - PIERS
'will do the work.and the micame is nut'mmadcd m offered is,,sale(Sce.7044:
Rosiness and Professions Code:The Commnor'.s Liwnse Law does not apply to an 103 - UFER Required Inspections'
owner of Fmny Who build.or improves thereon,and who does such work himself 104 - REBAR
or his own employees.provided that.such Improvements are not intended or l ... .
offend rorsak.If.hnwevr.the building or improvement is wild within One year of 105 ANCHOR BOLTS
completion,the owncemilder will have the barriers of proving that he did not build or 106 — SEWER & WATER
improve purpose,
_. ... .. . .... .. . _.. _ ..._ . 202 - UNDERFLOOR PLUMBING-
°1:as owner of the property,am exclusively contracting with licensed contcdcmns to
consumer the protect(Sm.7044.Business and Professions Cale:)The Can uacmr's 2 03 - UNDERFLOOR MECHANICAL
License law does not apply no an awmr of property avid,builds or improves thereon,
-and who.commcts for such projects with amunicmrl.).hrns d pursuant to the 204...- UNDERFLOOR FRAME
e Law
Contract.,,
1 om exempcunder Sr. a .B&PC for this bawn 205 — UNDERFLOOR' INSULATION
owner Data " 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
• l hereby artion coder penally of perjory One f,h,roROwing declera mm: 303 _ ROUGH MECHANICAL
° 1 have and will mai a Crtiecam of Consent to self-insure for Workers 304 ROUGH ELECTRICAL
Compensation, a, provided for by Section 37W of the Ichor Code, for the 305 - FRAME
performance of tee work for which Nis pc.I,is tamed, t
have ane win m in in woredrs comp nwyon Insurance.a,regnirod by section 306 _ HOLDUWNS
the Labor Cast for Ne performance w the work far which this permit i. 307 INSULATION
MY...
Y Works/s Comiaca'ation Imutoca c r and P I'y umher ore:
• . 308 ._ ..SHEETROCK. . .,. . _.
carritr'. Policy No.: "t 13'09 - EXTERIOR' LATH'
(This section need not be completed lithe permit is R .a.h.,dr
CERTIIgCATION OP EXENInION FROM W -
COMPENSATIONINSURANCE 3 L0`--.—INTER3OR LATH
,r ooa nondred dose:'^ .311 — SCRATCH COAT t, s•i
6100)or less.)
.I knir that he fbriOaam of mnwalrk roe which his t issued 3 13 ROOF NAIL . . .- - .
shall not employ any im a In any manner so a%to become subject totheWorker,, 501 — FINAL ELECTRI CAL t• ENERGY
Compepaamn Law,of C,rfOrnn,.Date 502 — ..FINAL .PLUMBING ENERGY
.Applicant :
NMICETO APPLICANT:if.air,,maoo,this Certificate of Exemption.you should 503 — FINAL MECHANICAL 'ENERGY
Z becowithco "dufficcomply
surkdzvisions or tion provisions
ercent strdr heeJnunl evoked.a mast 504 - FINAL BUILDING ENERGY
CC forthwith comply with such provisions or this pro ni
z-� ' t 'CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL •' ''
Ihekbyafloat thmNreisacon.weronlending agency formaparrommoo, 506 - GAS TEST I
'of the work for which this Permit is issued(Sec.3(197,Civ.C!
ysq ' c=oder°Name 507 FINAL PLUMBING
DZ Lender's Address' -- '
1 nify Nat I have read this npplicali in and stale that the above informmion is 508 — FINAL MECHANICAL
so
g. correct.1 agree to comply with all city and county ordinances and state laws relating 509 — FINAL GRADE
- O-U to building eonsametion.andherebyauthorizerepresentativesofthiscitytoenterupon 510 — FINAL PLANNING
1. W the above mentioned progeny for inspeclion proposes.
I„ a. ov=l agree tosave:indemniryand kcz,harod=saheCoy ofcnpenim,agahra 514 - FINAL PUBLIC
V1 liabilities,juJgmrna.costs and afren,e,which may in any way acerae against said
O_= City in comequenaeaFthe granting or this pe,air •'a /Q O /
APPLICANTU /SAND WILL WITH ALL lssuedb Dated
_ SOURCE ULATIONS. - Y
Sigmme Of, Contractor LS re Re-roofs
HAZARDOUS MATERIADISCLOSURE
.. will He apprtemm or mmre heading rathna,some Or handle ha,:wou,mam,i:d Type of Roof
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety ,
-I''f
Cotte,Section 255)2(4)" I, •,-;• ' l ' :: 4•
°res All roofs shall be.inspected prior to any.roofing.material being.installed._ .._..._...
'Will menpnhcamorfuture mildmgrecupantu,eequipment ordevirxwhich If a roof is installed without first obtaining an itispectiofi; I dgree'to'remove
emit haamdous air comamiaora,a,defined thyme Bay Arco Aii Quality Mxnngemem
Dieu l all new materials for inspection. Applicant understands and will_comply with
°Yc` StoI all non-point source regulations.; _
I have mad the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Coda Sections 25505.25533 wd 25534.I understm i t ion -
like uilNn icunehtly have a tenant.that it is my reser asthility to notify the -
comp the require nu which must be at r nr to i.m. ce of a Cenilica o!
Oesmancy.
. �• - Signature of Applicant Date
'owner ora a Data roof coverings to be Class `B" or better -
._..'.! - OFFICE