04090285 CITY OF CUPERTINO ' " —
13UILDINGDIVISION PER �uzGONTRACTORINFO A aN
BUILDINGADDRESS: - PERMIT NO.
SHENGI S CONSTRUCTION CO 04090285
OWNER'S NAME: PERMIT ISSUE DATE
all PHILIP LI
E:
SANITARYO. OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOZp LICENSED CONTRACTOR'S DECLARATION - - -
2.E C 1 Mreby affirm Ilia I am licensed under i m if ons or chapter 9 minaret neing JOb DOSCrlpt100
n<i with Scyion ")of Division 3.1'0 Rusin ca�di R.I.W.Codc.and myliccvcis
In
dean I Li_ o REVISION--TRUSS CAL
J M Z In In, 3 Lk.N
—o Date camtrelaryon TCf NO NEW PERMIT ISSUED/ORIG. #04030192
CH CPS DECLARANON
Y plans shall W used az public records
JyU G
U ose nscd PAdcssiun
gtoS OWNER-BUILDER DECLARATION
9 y I W¢by alTrm Nal 1 am exempt from We ATIONf3 License Law for IW - ---- -
O Ofollowing mann.(Secuu
hich"Forms a pen 11131.5.Business and Pmfcssiuns COW:Any oily or county
K$ wrmit m construct.oiler,improve,demolish,or repair any motion:
Liepriormilsissuanee,almmquimslWapplicansforsuchpernillofileasignedsmwment
Nal he is licensed pursuant to We previsions of the Contractor's licence Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
R,ii-c'-O (commencing with Section9110D)of Division Sof the Businessand ProfessionsCole)ur y -
'd 5 than he is exempt themfmm and We basis for the alleged exemption.Any violation of
Section 1031.5 by any applicant for ape Mail subjects the applicant o a civil penalty of APN Number \ Occupancy Type
not mom than five hundred dollar
I,as owner of me progeny,or my employees with wages as Nair sole compensation, 35715079 . 00
will do We work.and the swaurt is not intended or offered for Sale(Sec.1064,Business
Required Inspections
and Professions Code:TOO Canuactoh License Lsw does WI apply to an owner of
property who builds or improves thereon,and who docsauch work himself or though his
Own employ=,provided Nat such improvements am nosintended oroneted tornado.If. - - --
however,We building or improvement is sold within one year of complcuon.We owner. -
builder will have the burden of proving Nat he did not Wild or improve for purposes of
salt.).
1,as owner of W propcny,am exclusively contracting with licensed contractors to
construct the project(See 1044,Business and Professions Code:)The Contractor's Li- .
cense Law docs not apply in an owner or property,who Wilds or improves thereon,and - -
whocoosncteforsuchpmjccuwithaconsrecmr(a)licensed pursuant in the Conuacsofs _ .s
License UW. - - -- -
❑IamexemptunderSec. ,B&PC for Nis mazon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affum under penally of perjury,one or the following declarations:have and will maintain a Ccrtificare or Consent to self-insure for Wo lux'sCompen-
station.as pmvjdcd for by Section 31W of We L Wr Code,for We performance of the -- -
work for which this permit is issued.
Q-Ihave and will maintain Worker's Compensation Insurance,az required by Section
3100ofthc LSWrCode.far Neperformanceorthewwkforw hNispermitisissued.
M W rker's.Co cion lnsura carie and Poli n ram:
y p C ansa 4 C PaliN FROM
,
6/✓vo/[J CERTIFlCATEOF XTIONI NFROM WORKERS'
COMPENSATION INSURANCE '
This section need not W completed it the permit is forone hundred dollars(SI W)
or Lit
I sanity Nes in the Performance of We work for which this permit is issued,l shall nut
employ any person in any manneran az to become subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,arm,making this Ccnificate or Exemption,you should
become subject to the Worker's ComPcnsauon provisions of the Labor Care,you must
.J O forthwith comply with such Provisions or this permit shall be deemed tevoktd.
Z' CONSTRUCTION LENDING AGENCY
[-. I bemhY Orion Nal then is a construction lending agency tar the performance of
C' We work for which this permit is issued(Sec.3091,Civ.C.)
Ik]
UnderS Namc
1 'ider'i Address
O Q 1 certify that I have read Nis application and stets that the above information is
correct.1 agree to comply with all city and county on inzmces and stete laws relating to
V building construction,and hereby authorise munumnutives of this city to enter upon the
w aWve-mendormd Property(.I inspection Purposes
(We)agree to save,indemnify and keep harmless We City orrCupcnino against
r N hibiliues,judgmcn¢coslstod cxpcnscs which may in any way ac9gainslsao Cil,
U in consequence of the granting of this permit.
^ A ]CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
SOyR��¢MATIONS.
q
J/ I n 'o✓] � Re-roofs
Signawrcof Appl anUCon mr Date
HAZARDOU TERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cope)nice M7al
al Code.Chapter 9.12,and the Hcalsh and Safety
Cods.Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
0y.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remo e
s haxardnus air conteminanss az defined by the Bay AM.Air Quality Management all new materials for inspection.
Distriw?
Ctrs %K.
1 have read Ino hazardous materials mquimmcn55 under Chapter 6,95 of the Califor.
nia Health&Safety Cook,Sector.25305.25533 and 25534.1 undcrman if We Wilding
doesnos rely have a¢naw.WI it is my responsibility m and Iy W hpant of the
myu c swhi<I (Winet dormissuanccoraCenifmateaf 0
9Signature of Applicant Date
Owner or autha'xc aFcm 1 oa All roof coverings to be Class "B"or better