02120002 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT °CONTRACTOR INFORMATION:`
nulrlapC3 gpSSOMERSET CT WONG WILSON T AND SUSAN S PERMITNO2120002
ONGALWILSON T AND SUSAN S APPLICA1IP'2SjtIT1'2Tf 2002
IONIi: SANITARY NO. CONTROL NO.
ARCIIETECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
wOp LICENSED CONTRACTOR'S DECLARATION ]lj�jjQQqq..
n�zF lion by a
7NLofDihwlam foo ed Bui nrsand ProfessonsCode.asof Chapter nmy license
KITCHEN & DFi`E fUU�L
<3 in ofI fume an lgBnf Division h4thc❑usinessand Professions Code.and myliccnscis
t—Dy
in Class and effect. D
�Z
License Class o
O Z—^ Uwe Coulmrxcun
F= ARCUTI-E SDECLARATION MAY 2 7ZOO 3
�Yiyre� I understand my plans shall the.,oil as public records
%0 ad
=LLC
Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
s�m 1 hereby affirm that I am exempt from the Comrannr's License law for the ` NC $30000
cif 00 following mason.section 7131.5,Business and Professions CWe:Aayeity or county
exe. which requires a permit In consumer,alter,improve,demolish,or repair any mrunme
FZ< prior to its issuance.also"roms the applicant for such permit to file a signed statement
that he is licensed pursuant to the prnvisions of the Contractor's License Law(Chapter 9 3S"y9H9Alo3�A@0 Valuation
Sd�C (commencing with Section 7Wg)of Division of the Business and Professions Code)or
.c that Its,is exempt therefrom and to Wide far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pmmitsubjects the applicant to a civil Penalty or 1`JAIyNNWRRFDA1iUN Occupancy Type
net more Nan five hundred dollars(9500). 102 — PIERS P Y YP
I,as owner of the prepeny,or my employees with wages as their belt compensation,
will do the work,and the income is not moored or offered for sale(See.7W,Business 2:03 UFER
and Professions Cade:The Contractor's License law does not apply to an owner of 104 - REBAR Required Inspections
propcny who buildsor improves Hereon,and who doessuch work himseRor Nmugh his
own employees.provided that such improvements arc not intended or offered for sale If, 105 — ANCHOR BOLTS
bravown the building or improvement is sold within one year of completion,fee more.
builder will have the burden of proving that he did not build or impmve for propose of 106 - SEWER & WATER -
sale.)' 202 - UNDERFLOOR PLUMBING
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to 203 - UNDERFLOOR MECHANICAL
crosuuct the project(Sea 7W.Business and Profesaions Code:)The Contreclols Li-
censcLaw mors not apply to an owner of property who Wilds or improver themon,and, 204 - UNDERFLOOR FRAME
Liocnm Lew�f.r such prnjecuwiNattmtracmr(s)licensed pursuant the Contractor's 205 - UNDERFLOOR INSULATION
I am exempt under Sec. ,B&P C far this..on 301 - ROUGH PLUMBING
m LUIl�0/J d bt�3}'N CQ DN te ?-,0 302 - TUB & OR SHOWER
A WORKER'S COMPENSATION DECLARA-�M 303 - ROUGH MECHANICAL
I hereby affirm under Penalty of pmjury one of the following declarations: 304 — ROUGH ELECTRICAL
❑l have and will maintain a Certificate of Consent self-insure for Worker's Cnmpem 305 — FRAME
satinn,es provided for by Section 371X1 of the Islam CWe,for the perfusmenm of the
work For which this Permit is lured. 306 - HOLDOWNS
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section 3 0 7 - INSULATION
J71N)of Ne Labor Code,for Ne performance of the work for which this permit is issued,
My
Worker's Compensation Insurance carrier and Policy number am: 308 - SHEETROCK
Carrier: Policy No.: 309 - EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This sectionneed not he completed if lM permit isformte hundred doll.CSINB 311 - SCRATCH COAT
unless.) 313 - ROOF NAIL
I ctnify that in Nc r +ante of the work for which Nis permit is issued,1 shall nm 5 01 - FINAL ELECTRICAL ENERGY
Im
Laws o(nelif+nie,D mann raou tu`Mc,mvthjcn tot orkcrs'Compcnscion
,
3 502 - FINAL PLUMBING ENERGY
App
NOT '1'OAPPLI ,altcrmann thinCcnilicat nlExcmpfinn,ytuahuulJ 503 - FINAL MECHANICAL ENERGY
We.
xuhjen unhc orker's Compensminn pnrvisionsn the lahnr COJe.you mass 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions onhis permit shall JcemeJ revoked.
'z CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
[r 4 (hereby affirm Nat more is aconsnctionlending agency for the Performance of 506 - GAS TEST
x > Lme and or which Nispermitisissued(Scc.31Y)l,Civ.C) 507 - FINAL PLUMBING
tLl Q Lenz's Name
z LonderaAddress 508 - FINAL MECHANICAL
U O 1 comfy that 1 have read this application and sort that No above information is 509 — FINAL GRADE
(—' comect.1 agree to comply with all city and county ordinances and sum laws relating to
Obuildingcnnsnction.andherebyauthorizempriecatatinceofthiscityinenterulumthe 5 FINAL PLANNING
6Uwi
.how-mcntioned property for inspection proposes. 14 FINW RKS
(We)agree m save,imbo nily and keep harm loss Ne City of Cupertino against
lzy liabi lines,judgments,costs and expenses which may in any way same againstsaid City /
in (if the gratin ag of
consisl
V ^� AP LIC Ye TcUNDERSTANIhoNo WILL COMPLY WITH ALL NON POINT Issued by: Date I or"
5 RCE : SDS
this
Re-roofs
Signature fApplicam/ ontracor am
HAZARDOUSMATER AIS ISCLOSURE Type of Roof
Will Ne applicantor future building occupen state or handle mandous material
efned by the Cuptnino Muniei Code.Chapter 9.12,and the Health and Safety
Scnion 25532bd? All roofs shall be inspected prior to an roofing material being installed.
❑Yes P P Y g g
Will the applicant or future building txcupont use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
cm it hvamous air contaminants asfined by the Bay Arca Air Qualify Management
all new materials for inspection.
Distridt
❑Yes
1 have mad the hazardous materials requirements under Chapter 6,95 of the Caliber
niallcalN&Sty Codc.SttBsass 2.55115.255JJ and 255Yt.lundcrsunJ NmildM Wilding
Jms nut cu i y have a meta,tlit is my re"nsibility to notify IM rccupant of me
mgriyryCnu mnerpancy,
mruhemelp- rmiaaranconr. . iEtterrSignature of Applicant Date
�a 1 1
Owner or authnriacJ agent Dom All roof coverings to be Class "B" or better