04050059 (2) CITY OF CUPEWfINO
BUILDING DIVISION PERMIT 1�COIVTRACTORRR1VFiORMAT,ION
BUILDING ADDRESS: RYAN HU """"04050059
ERMITNIT.4050059
6c;77 rT,TFF0?r) FIR
OWNER'S NAME: PERMIT ISSUE DATE
MENG-
lor E:
SANITARY NO. CONTROL NO.
(650) 343-8038
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION
M F I hereby affirm that I am licensed Under previsions Of Chapter 9(commencing Job Description .
`9• with Section 7W))ofDrown.3 o NC Business and I'mmasiom Coc,and my license is
> imBit bmeadd effect.
REVISION--IN HOUSE USE ONLY
j n= Lt..Class Lic.0
So Dae Contrscer ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. 403100171
I uMcrstand my plans shall he used as public records
JyU
G Licensed Pmfcssionel
qv,5 OWNER-BUILDER DECLARATION
y 1 bcehy affirm that 1 am exempt from the Constance,License Law for the
5
no following reason.(section 7031.5,Business and Professions Code:Any City or county
SIR! which requires a Permit to construct,alter,impmw.demolish,or repair any mr ctum
FIy pd.,to its dauance.m.requires lheappllcam farauch Permit,.ltleaalgnedstaterem
< that he is liccrted pursuant to the previsions oftbc Contractors License law(Chapter9 Sq.Ft.Floor Area Valuation $0
�Fm Mornmeneingwith Suction700))of Division3ofthe Buvineasand Profcasions Crile)or
i Nat he is exempt Macaroon and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
ad,...man r hundred dollars(,500). 36926005 . 00
❑1,as owner of the property,m my employees with wages ns their sole compensation,
will do the work and the swctuu is not intended or offered farad.(See.7044,Business
and Prefrssiom Coda:The Cnnvssurs License Law does not appy to an nwner or Required Inspections
property who builds orimproves thereon,and whodosesuch work himself or through his
n employees,provided Nat such impmKmenu arc not intended oraRered forsale.If.
however,the building or improvement is Sold within one year of impletion,me owner
builder will haw the burden of Proving that he did not build or improve for purpose of / \
sok.). \O
❑h as owner of IM property,am exclusively contracting with licensed comernmrs e
comtmct the prejem(Sec.7814.Business and Profession Cade:)The Contractors Li-
Same law does not apply m an owner of property who builds or impowa Nemo.,and
who contracts for such projects with a commanders)licensed pursuant to the Contractor's
License Law.
❑1 erre exempt under Sec. .B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby atfum under penalty of perjury one of the following dcclaratiom:
have and will maintain a Certificate of Consent m self-insum fur Workers Compere
ren,u provided for by Section 3700 of the Labor Code,for Ne performance of Ne
wank for which Nis permit is issued.
1 Mw and will maintain Worker's Compensation Insurance,as required by Section
3700 of me labor Code.f".performance of the work for which this permit is issued
My Workers Compensation Inwrame carrier and Policy number are:
Carrier: Policy No,: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
oldescaion need not beeompleted if the Permit is forone hundred dollen($109)
or Max.)
I Sartify that in the pufurmutce of the work for which this permit is issued,I shall not
employ any person in any manner an as m become subject to the Workers'Compemation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccniricae of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
.J O mdmvid comply with such provisions or this permit dull be deemed revoked.
Z r~N. CONSTRUCTION LENDING AGENCY
E•. I hereby oMo.that dere is a construction landing agency fm the perfimmmuce of
de work fur which this permit is issued(Sec.3097,Co.C.)
fa]Q Landers Name
0.
z Lender's Addtus
U
U Q 1 certify that 1 have read this application y o sate Nat the Sauw Information is
0 U coma agra to comply with all city and county mMoCa Of and Cott laws r up in t e
V ahOw'g unionectionanu herfor by mcq etiortaemoses. iws of Nis city to enter upon de
rW ahovcmemionree roparly to
lueep ea.
(Wc)agrees.saw,indemnify and kap locamedueal
an Bre City of Cupertino against
UZ liaemme,,judgmunco f thecmtsandof this penah. may in anywry aSame against said City
V z to
UNDERSTANDSANDWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ile applicant or future building e,aspect
mom or annuls h eardrm material
as defined io de Cupertino Municipal Code,CTaper 9.12,and de Heald and Safety
Code,Section 25532(a)7
❑Yes ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will Ne applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t haxmdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
icO
❑Yrs ❑N.
1 have read the havarunus materialsmquimmenu under Chaper6.95 oldie Califon
niaHwlN&SafctyCadc.Scmiom 25505,25577 cod 25531.1 undcrsuM tMtif Nc building
does mol curmnlly haw a enanLNat it 4 my mspomihility a notif y the occupant or the
requirements whim must be met poor to women of a Certificate of occupancy. Signature Of Applicant Date
Owner or aumomcd agent Dae All roof coverings to be Class•'B" or better