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CITY OF CUPERTINO
DIVISION PERMIT
CONTRACTORV. x RMATION --,
BUILDING
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BUILDING ADDRESS:
AMERICAN BRANDS CONSTRUCTI
MITN004060173
20903 HANFORD DR
OWNER'S NAME:
PERMIT ISUEDATE
ZHAORONG XIA
1145 HAWKS HILL ROAD
yE.
SANITARY N0, CONTROL NO.
(408)210-4945
ARCHITELTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
m m 1 licensed under pmvismax of Chapter 9 (commencing
I hcmby afford Nam
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withSecti 7 Bnf Division Bof the Busi dProfessiuns Code, arta mylicenu is
in mumrc erreat. 3-07
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PATIO POOL ENCLOSURE (546 SQ.FT.)
C acs Lie. _s
D Convect
' ATION
ARCHITECTS DEC
I undcrvand my plans shall M used u public moods
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Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm Not I am exempt from the, Conlractofs License Law for the
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fallowing mason. (Section iBJ L5, Bu5inc5a and Plafessiona Code: Any city or county
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which cultures a permit to construct, aper, improve. demolish, or repair any structure
S5 8 5 2
prior to its issuance, also requires the applicant torment Permit m rile a signed statement
Ft. Floor Area
Valuation
thatW ulicenscd pursuantm the provisions of the Contractor's License law(Chapter 9
Sq.
Cad
(eamencing with Section 7000) of Division J of the Business and! Proressiov e? ar
m
Nal he Is exempt therefrom and the basis for the alleged exemption. Any violation of
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Occupancy Type
Section 7071.5 by my applicant for a permit subjccss dm applicant to anvil penally of
net more thm five hundred dollars (M).
❑ 1. as owner ofthe property, or my cmployeu with wages as their solo compensation,
Required Inspections
will do the ..,it. and the mwuture is not intended oroffered for sale (Sec. PWA, Business
and Professions Code: The Contractor's Limme law does not apply to an owner of
property who builds or improv Ihercan, end who dnesauch work himulfar tlwugh his
own cmployaea, provided Nat tech improvemmu art not sounded maRercd forsale. If.
however, the building or improvement is sold within ane year of completion. the owner -
builder will bac the Widen of proving that he did not Wild or improve for purpose of
saic.).
❑ h as owner of the property, am exclusively contracting with licensed contractors to
construct Ne project (Sec. 70,14, Business and Forma ns Code:) The Contractors Li.
cove law docs not apply in an owner of property who Wilds or improves menton, and .
who moment for such projeeu with a eommactor(s)licensed pu mnt to the Contractoes
Lt.. law.
❑ I am exempt under Sec. ,B&PC for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
. have and will maintain aCer iflPu of Covent to self -insure for WorketsCompen-
sation, as provided for by Section 3700 of the labor Cade, for the performmrce of Ne
work for which this permit is issued.
I have and will maintain Worlds Compensation Insurance, as required by Section
1700 of the labor Code, for Ne performance of the work for which this look is issued.
My Worker'ssCCompensation.-lnsunnde carrier and Policy number am:
rY
'wS\&t�e F-�sws�C` Policy //3art73O
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CERTIFICATE OF EKEMPnO=M WORKERS'
COMPENSATION INSURANCE
Ohu section need not kcompleud if tW permit is formic hundred dollars (SIM)
or Ices.)
1 cenify Not in the performance of the work for which this permit is issued. I shall not
employany person in any manner m as to become subject to the Workers Compensation
Laws of Califomia. Dau
Applicant
NOTICE TO APPLICANT: If. after making this Ccreficau of Exemption, you should
became subject to the Worker's Compcwtian provisions of the labor Code. you most
fothwith comply with such provision, w mss I<rmit shall W deemed rtwkxd.
CONSTRUCTION LENDING AGENCY
I hereby that mere is a lending agency lar tW Performance of
which nd (Sec.3
the work for which this permit is issued (Sec. 7091. Civ. C.)
lenders Namc
.
landcrs Address
j I svtify that I have read this application and sum that the shout infsmmon is
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' correct 1 agree to comply with all city and county commences and sure laws mlating to
building convection, and hereby authorire representatives of this city to chair upon the
above-mcntiuncd property for inspection purposes
(We) agrte to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against saidCity
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC ULATI NS.
Re -roofs
Type of Roof
ignawr or Applicant/Con Oicmr eta
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant store or handle hvmdoua material
as defined by the Cupertino Municipal Code. Chapter 9.1'2, and the Health and Safety
Code. p`ru zssJ2(.)?/Nd
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or dcvicns which
marardous air contaminants u dc0ncd by the Bay Area Air Quality Management
all new materials for inspection.
oriet' /
❑Yes
1 have mail me hvaoous mamriala requirements under Chapur6,95 of flu Cslirm-
hisHealm&SafetyCode, Sections 25505, 23513 anJ 255Ja. l mulme al thuifthe Wilding
does not currently haw m unam that it IS my responsibility to many the occupant of the
mquiremcnuwhi hmust met paor pr ren Crinfiea of OcaWe
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner crap .rived agent Dau