09060004 CITY OF CUPERTINO -pp:
BUILDING DIVISION PERMIT � L1Z� �N*
BUILDING ADDRESS: PERMIT NO.
18915 TI —
^WNER'S NAME:
PERMIT ISSUE DATE
PMON : 14A & HELEN TRAN S A CONTROL NO.
ARCHTTECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � 0
u 0 C LICENSED CONTRACTOR'S DECLARATION Job Description
IgI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z . with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=o in full force and effect ADDITI0A 2 3 9 'ENLARGE(E) DINING & LIVING RM.
License Class Lle•M
Date Contractor
t— ARCHITECTS DECLARATION
tt I understand my plans shall be used as public records
jyU
U.y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for ftMin following reason.(Section 7031.5,Business and Professions Code:Any city or county
K$9 which requires a permit to construct.alter.improve.demolish,or repair any structure
n"- prior to its issuance,also requires the applicant for such permit to file a signed statement
rc G
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor Area Valuation
Y.t- (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
y
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 APN Number Occupancy Type
not mote than five hundred dollars(5500). 3 7 514 01 a . 01
0 1,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 for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dors not apply to an owner of q P
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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contracmrs Li-
cense Caw 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 B&P C f this n
ner Date
WORKER' C SAT N DECLARATION
I hereby affirm under penalty of pg.rjttly one of the following declarations:
0 I 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.
0 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 Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which Lkis permit' issued,1 shall not
employ any person in any manner so as to become sub' rs' mpensation
Laws of C
Applicant
NOTICE TO APPLICANT:I makrn this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
'Z, forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(ter tom+ I hereby affirm that there is a construction lending agency for the performance of
�ithe work for which this permit is issued(Sec.3097,Civ.C.)
WLL A Lender's Name
►0 z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
ly►� correct 1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
H a (We)agree to save,indemnify and keep harmless the City of Cupertino against
„t rA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Gj
r't APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date i
SOURCE REGULATIONS. I 1yZA1a4 ':7 6�/$_'
Re-roofs
Signature of ApplipnUCon rotData 'I of R)of
IIAZAR SMA blSCLDSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino MuniVpal Code.Chapter 9.12,and the Health and Safety
_1c.Section 25532(a)? All roofs,hall be inspected prior to any roofing material being installed.
C3 Yes (±JNo
If a roof 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 defined by the Bay Area Air Quality Management all new m,iterials for inspection.
District?
0 Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafelyCode,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant;that s my responsibility to notify cite occas t of the
requirements which must be melissu of a Certificate of Signature A Applicant Date
All roof coverings to be Class'A'or better
Owner or authorized aget Da