07100009 CIT�' OF CUPERTINO ` " `
BUILDING DIVISION pER1VIIT ��.1�� �`T�fR I�'E���TI��1 '
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PERMIT NQ.
BUILD �� PL TBD Tc ) BE DETERMINED 0 710 0 0 0 9 .
OWNER'S NAME: � PERMIT LSSUE DATE
CHAO LI & D APH NE CHEN 10/01/2007
NE: SANITARY NO. CONTROL NO.
ARCHI7'ECT/ENGIIYEER: BU(LD1NG PERMIT INPO
BLDG ELECT PLUMB MECH
C7 O O 0
� o o LICENSED CON7RAC7'OR'S DECLARATION JOb DOSCClpt10❑
; v� 1 hcrcby �rm tha� 1 am liccnscd undcr provisions of Chaptcr 9(commencinS
;_, � wim Sccuon 7o(w) o( Di�ision 3 of mc Busincsc and Profcssions Code, and my Iicensc is UPGRADE K I TCHEN & BATHROOMS ( 2�
�� y in full focce and cffec4
�� Z Licensc Class L�. �►
: F , r p Datc Conuuwr
a ARCHITECI'S DECLARATION
i a a 1 undcrstanJ my plans shall bc uuJ az public rccords
>qU
' u. y Licensed Prufessional
� y � OW NER-BUILDER DECLARATION
�-' 1 hcrcby al'firm U�at 1 am cxcmpt Gum U�c Convactors Liccnsc Law for �hc
� p O Collowing sason. (Secuon 7(131.5, Busincss and Profecsions Calc: Any ci�y or county
� �,° � which rcqui�cs a pertnit to canswct, allcr, improvc, dcmolich, or rep�ir any suvcwre
� z y prior u� ils issuancc. alsa rcquires ihc applican� Cor such pertnit �a filc a signcd stalcmem �,
: s a �hat Ae is IiccnscJ pursuanl lo thc provisions of ihc Convactor's Liccnsc Law (Chaptcr 9 �� Ft. Floor Area Valuation
� t— �(commcncing with Sccdon 7000) of Division 3 of thc Busincss and Profcssions Codc) or � 5 � � � 0
,u, � r. that he is ezempt thc�efrom and ihe basis Cor the allcgcd exemption. Any violauon oC
Sectlon 7031.5 by a�ry applicant for a pertnit subjects �he applicant to a civil pcnalty of Number Oeeupaney Type
not morc U�an fvc 6undced dollars (5500). 3 6 2 21 � � ���
❑ I, u owner o( ttie property, o� my employces with wages as their salc compensadon,
wil! da the work, and Ihe swcture is not imm��d or oEfend for sak (Sec.7044, Business Re uired Ins eCtIOIlS
and Professions Codc: The Convacwr's License Law docs not apply a sn owner o� 9 P
propeny who builds or improves thereon, and who does such work himself or ihrough his
own emplayccs, providcd Wa� such improvements are not in�e�ed oraRered for sala 1C.
however, the building or improvement ia soid within ou year of compicdon, the owrrcrv
buitder will have Uu burden oC proving that he did nat build or improvc for purpou of
sa� J.
❑ I, as awner of ihe property, am ezclusively conuacting wilh licensed conuactors lo
conswct �he pcnject (Sec. 7044. Susinas and Professions Code:) The Conuactor's Li-
ccnse Iaw docs not apply to an owncr of propeny who builds or improves Uiereon, and ,
who conuac�s Cor such projects with a conuactor(s) licensed pursuant to �hc Convactors
License L.aw.
❑ I am uempt under Sec . 8& P C for Uiu� uon
�
Owner ��'-.�-l.U�(.�C� � t/ Date l � �
WORKIIt'S COMPENSATTON DECLARAT[ON
I hercby affirm under penalry ot perjury onc o( the fallowing declaraGons:
[] I hsve and will maintain a Certificate of Conscnt to self-insure for Workcrs Canpen-
sation, as providcd for by Sec[ion 3700 oC �e Labor Code, far �he performa�e of thc
woric tor which ihis permit is iuucd.
❑ I havc and will maintain Workcr's Compensation Insurance, u icyuired by Scctian
3700 oC ihc Labor Cadc, fw U�c performancc of the work (or which �his permit is issued.
My Workers Compensadon Insurancc carrier and Policy numbcr azc:
Camer. Policy No.:
CERTIFICA7'E OF EXEMP1701Y FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bc completcJ if the permit is foranc hundrcA dollars (E100)
or Icss.) �
I ceni(y that in thc performancc of thc work for which this pertnit is issucd, t shali not
employ any person in any manncr s ,tf'� omc subjcct ta t6e Workcrs' Compcnution
Laws of California. D�c
Applicant ��t� �
NOTICE TO APPLICA . If, aC�cr making �his CcrtiGca�e of Faccmption, you shoulJ
bccome subjcct to thc Workcr's Compcnsation provisions of ihc LaAor Codc, you must
� O foMwith comply with such provisions or this pccmi� shall bc dccmcd ccvokcd.
z "'' CONSfRUCTION LENDING AGENCY
[— � I hcreby al1'irm �hat thcre is a constnxtion Icnding agcncy for thc perfortnance ol' .
a., � ihc work fur which this pemiit is iuucd (Scc. 3097, Civ. C.)
W A Lendcr's Namc '
� z C.cnders Address
U � I ccnify �hat I havc rcad this applicadon and sia�c ihai thc abovc informariun is
� ►� cortcct. 1 agrce to comply with all ciry and county onlinances and state laws rclating to
� U building conswction, and hc�cby authori�e rcprescntativcs of ihis city to cntcr u�n thc
� W abovc-mcniivncd property (or inspccuon purposes.
a (Wc) agrce to save, indcmni(y and kecp hazmleu ihc City o[ Cupcnino against
�� liabilitiu, judgments, costs and expenses which may in any way accruc against said City
() z in consequencc oC the granting of ihis permi� Date
"'� APPLICANT UNDERSTANDS AND WILL COMPLY W1TH ALL NON-POINT Issued by:
SOURG G ONS. /'
� Re-roofs
SignaturcofAppli onuac �a� Type of R �)Of
AZARDOUS MATERIALS DISCLOSURE
Will lhe applicant a future building accupantstorc or hand(c ha•rardous matcrial
az dcfincd by the Cupertino Municipal Codc. Chaptcr 9.12. and the Hcal�h and Safcly
c� Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
�y� ❑No
Will ihc applicant or fmucc building occupant usc cyuipmcnt or Jcviccs which
If a roof i: installed without first obtaining an inspection, I agree to remove -
cmi� ha•rardous air con�aminan�s as dcfi�d by the Bay Arca Air Quality Managcmcni all new m: iterials for inspec*ion.
Disuict?
❑ Ycs ❑ Nu
1 havc rcad the hvarCous maicrials requiremcnLt undcrChap�cr6.95 af �hc Califor-
nia Hc�lth & Safcty Cadc Scctions Z5505, 25533 anJ 25534_ 1 undcrstand that if ihc buiWing
docs not currcnU havc a �cnant, ihat it is m ponsibiliry �o no�fy Uic axupant af ihc
re� must bc met p�or w' ota Ccrtificaic of Occupancy. /' Signature �f Applicant Date
—� All roof coverings to be Class "B" or better
Owncr or authori• agcni Datc