06120108 CITY OF CUPERTINONK
BUILDING DIVISION PERMIT Co XTQ I0 '
PERMIT NO.
BUILDING ADDRESS:
21872 HERMOSA AVE JOSEPH YEN 06120108
PERMIT ISSUE DATE
OWNER'S NAME:
JOSEPH YEN 02/23/2007
SANITARY NO. CONTROL NO.
INE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
p C LICENSED CONTRACTOR'S DECLARATION Job Description
%m !hereby affirm that I am licensed under provisions of Chapter 9(commencing
i with Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMO E?.I ST I NG S FDWL
t c w in full force and effect
License Clac , L •# G
p Datc O� O Contractor
mARCHITECTS DECLARATION
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U understand=ns hall be us blic records
O in Licc ssiona
/ ER-BUILDE LA AT10N
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z I hereby affirm that 1 am exemp rum the ntractoes License Law for the
in O following reason.(Section 7031.5,Busi ess and Pro scions Code:Any city or county
which requires a permit to construct,al impro ,demolish,or repair any structure
z y prior to its issuance,also requires the applicant or such permit to rile a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $15000
i t= (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
i as that he is exempt therefrom 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 �1 Number Occupancy Type
not more than five hundred dollars(5500). 35716051 .
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered forsate(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Somlynsation Insurance carrier and Policy number are:
Cartier lVd Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provision or this permit shall be deemed revoked.
z. CONSTRUCTION LENDING AGENCY
[~'t 1 hereby affirm that there is a construction lending agency for the performance of
tYi the work for which this permit is issued(Sec.3097,Civ.C.)
LI:1 A Lender's Name
]Z Lender's Address
U C I certify that I have read this application and state that the above information is
w►"
Co CL I agree to comply with all city and county ordinances and state laws relating to
0 ing construction,and hereby authorize representatives or this city to enter upon the
V build
Uabove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
,Fy liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date2l
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued f y:
SOURCE REGU S.,
� 013 ° Re-roofs
Sr o A 'Contras
° T of Roof
USM ALS D[SCLOSllR Type
Will the appli or future buil ng occupant store or handle hazardous material
as defined by the Cu Mum • Code.Chapter 9.12,and the Health and Safety
Code,section 25532(a)? All roof's shall be inspected prior to any roofing material being installed.
C3 Yes XNo
If a too 7 is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes /Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
rcquirements�whiclmet prior once of a Certificate of Oc pang. Signatu-e of Applicant Date
`� All roof coverings to be Class"B"or better
Owner or authorize c are