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CITY OF CUPERTINO � :. ? 'rah';+
BUILDING DIVISION PERMIT CONTRACT=ORbrINFORMATION Y
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BUILDING ADDRESS: RYAN HU PERMIT N'04060098
OO4060098
6577 CLIFFORD T)R
OWNER'S NAME: PERMIT ISSUE DATE
AM MENGCHEN YAO
lop ONE: SANITARY N0. CONTROL N0.
650 343-8038
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
t
0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION IO Description
y w FF 1 bereby affirm Nal I an,Readmit mulct provisions of Chapter 9(commencing
Sia`3 wild Scotian 901)11)of Division 3 of the Basins and Profassions Code,and my license is q
in foil to=and effect. TEMP POWER POLE ONALE®
Licenac Chis Lk.a
n—p Dec.Convector
�ZZ',1 ARCHITECTS DECLARATION JUN 45` 2004,
C i I mmandnl my plans shall M used u public records
yU
3 w t' Licensed Ptedca nal
ito
OWNER-BUILDER DECLARATION BUILDING
UI ®IIS�tlG
I heachy CIE.Not I am exempt from de Contractors License Law for the Y 167J
00 following easnn.(Sation 913 IS,Business and Pmfcaxionv Cade:Any city or county
KS which require st .it m Consumer,elect improve,demolish,or.,I, a,...to.
w—N prior at its issuance,also r:quiea the applicant for such permit to Glc a signed sdealml
that he is licensed pursumu to the previsions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
ad (commencing with Section 7")of Division 3 of the Business and Professions Crete)or
i $
that he Is exempt therefrom and Be basis for the alleged exemption.Any violation of
Section 7031.5 by airy,applicant for a permit subjects the applicant m a civil pcnahy of 3 6e243Q 0aer0 0 Occupancy Type
notI m Nan Ban hundred dollars($500).
®'1,.meanest of Be property,OF my employees with wage as their sole campensadon,
will do the work and the..ctom is not muoulad or offered for sale(Sec.7014.Business
and Professions Code:The Commuters Liceme Law Kaes not apply in an owner of Required Inspections
property who builds or improves Nerean,and who does such work himself or through his
own employees,provided that such improvements arc not intended oroRered formic.If.
however,the building or imprevereent is amid within one year of sump men,Ne owner,
builder will haw the burden of proving that he did not build or improve for Pon=of
Cold.).
❑1,as rower of the propenY,am exclusively contracting with licensed romrmmrs to
construct the p.jen(Sec.]oda,Business and Profeasia.Code:)The Convenors Li-
cense law docs not apply in an owner of property who Wilds or improve themon,and.
who con.U for such projects wild a contractors)licensed pursuant m the Cmntranmrs
License law.
0I am exempt a/nddeer Sec. ,B&P C far this Mason
Owner -/./!//A�.i✓/�II Date Usv ar
— W K R�'SCOMPE iv
DECLARATION
1 hereby afRrm under penalty of perjury one of the following deeluations:
1 ban and will maintain a Certifia¢of Convent to self-iasme for Workers Campen-
aasion,as provided for by Section 3700 of the Leber Code,far Ne pe rmarm.of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3900 of de Labor Code,for de Performance of Ne weak for which this permit is issued.
My Woder's Compewtion Iownna carie,and Policy number are:
Cork, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed 11014 permit is forma:hundred dollars(SIM)
or less.)
1 certify that in the performance of Nc work for which this Permit is issued.I shall not
employ any Forma in any manner so OF in become subject to the Worked ComPenvtion
Laws of California.OF
Applicant
NOTICE TO APPLICANT:if,afmr making Nis Cenifim.of Exemption.you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
,J2 fanhwith comply with such provisions or this Nadi t shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Ihereby affirm that then is a Com.ction lending agcnry for the Performance of
a 7 the work for which this permit is issued(Sac.3WT,Civ.C.)
dLanders Namc
2. 0 4ndcr's Address
U(] 1 modify that 1 have red this application and sue Nat the above information is
F' covccL I agree to comply with all city and county ordinances and added laws elating to
0U building construction,and hereby amhoriwrprsematives clubs city to enter upon Nc
r W shove-mentioned pmNrty for inspection partakes.
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
F•' h Iiabilitimpd,nuns,coati add C., .which may in any way Ore..,east said City
U in conaequenec ofthe granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R TIONS.
Ey6�/ Re-roofs
Signaturcef ApFIj�UComncd / Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant store or handle hadommus matenal
u dofincd by thin Cupertino Municipal Caw.Chapter 9.11,and the Health and SRey
cele. 0y.zss3z(a)? All roofs shall be inspected nor to an roofing material basin installed.
❑Ye P.
P P � Y g g �
/ Will thc applicant or future building occupant mac equipment or dcviaa which If a roof is installed without first obtaining an inspection,I agree to remove
emit hannuous air contaminants sa defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 haw read Ne hvardous materials requirements under Chapter 6.95 of Ne Califor-
Fix Heard&SafetyCoM,Sectors 15505.23533 and 25534.1 understand Nat if de Wilding
doe not concnd haw a ender,Nath is my mapoeihility to notify do occupant of Ne
acquie Ch moR IIT. ria sm or.cmdricawdfyree�ey.O Signature of Applicant Date
Owner or autho red agent b „e All roof coverings to be Class "B" or better
Community Development
/ 10300 Torre Avenue
4/ Cupertino CA 95014
X ,.
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
WUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: -e PHONE #
GENERAL CONTRACTOR: I,t FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
65 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork .
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
� 60f/0
GVner/Contq�/ctor Signature Date
51M
CITY OF CUPERTINO �/ 6 v 72-
TEMP POWER
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UPERTINO PERMIT APPLICATION FORM
APN # Date: II D
Building Address:�
Owner's Name: Phone
Contractor: p Phone S Y� License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description: I'wC
Te�A ora �ow2r
Residential {-il Commercial ❑
Cost of Project:
Qty. if
A2plicable Fee 1D Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING