06030022CITY OF CUPERTINO
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BUILDING DIVISION PERT
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BUILDING ADDRESS: -
PERMITNO. 06030022
10430 LANSDALE AV
WS NAME:
PERMIT `L SUBDATE
JINGANG SU
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECVENGINEER:
BUILDING PERMITINFO
BO ELECT PLUMB MECH
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LICENSED CONIRACIOR'S DECLARATION
o
Job Description
1 hereby aM m Nal 1 am licensed under previsions of Chapter 9 (commencing
Hth Swtion7")of Division3afthe Bud and ProfeWan Code.andmyIicuueu
infnlLforeeandeffeo.
ADDITION 1391-GAME ROOM/PATIO COVER
License Class Lie.a
Data Contractor
ARCHITECTS DECLARATION
1 understand my plana shall he used as public mend
'
Licensed Prefectional
OWNER-BUILDER DECLARATION
1 kreby affirm Nat I am exempt from the Camnctoes License Law for the
-
following ore (Smtion 71313, Business end Prof sats Code: Any city or county
which requirns a permit to eonmmCt. ilter. improve, demolish, or tepour any stmmure
$29797
prior to its Issuance. Alan requires the applicant for such permit to Ek a st oed ataument
then No is licensed pursuant M tho provisiensof thc Comrscur'a lxemc Law, fChapur 9
Sq.Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of Ne Bnsinas and professions Code) or
Wt he Its exempt therefrom and the basis for the alleged exemption. Any violation of
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Occupancy Type
Sectiw 7031.5 by atry appllcmt for a permit objects the applicant to a civil penalty of
trot mom than fin hundred dollars ($500}
❑ 1, as owner of de pmpwy. army employee with wgu u thek salt wmpenudon,
Required Ins actions
will do the work, and theauueTum Is notimaMed osoRened for, sale(Sm. 7044. Business
end Professions Code: The Contsactoes License Law does not apply to in Owner of
q p
is
himwlrmlluoughhu
pmpenywho builds arlmpmvsuch
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ownemptoyees,pmNded Nu wehimpmwmwo arenotneMed osselforhrough
ImpraMwWamnoLimende
I[E,l�
wner
however, the Wilding or improvement is mid within an year of completion, the owner-
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builder will have the burden of proving that he 414 not build m improve for purpose of
builder
Uy
Asia.).
X. 1, ea owner of the property, am exclusively contracting with licensed conwmon to
construct dre jxct (See. 7044. Business and Profusions Code:) Toa Contractor's U-
conspao
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4.
cease law doe not apply m an owner of p rmeny.who Wilds or imporm thereon, and
who contracts for such projects with a conu enum(s) licensed pursuant to the Conwnara
y
Lkenee law.
O lamaemptunderSw ,BRPCforthismemn
�n'ry('lr�Jl
.IIjJ� Ul'ItJ"�iy\wClr'ffl [/{`,JL'�/'
ICAsData
A s C-®RPENSATION DECLARATION
,
I hereby af0rm under penury of perjury arc of the following declarations:
❑ 1 hew and will milnuin • CendBnse ofConsem to self-iuwe fos Wmkar'a Compere
nation, As provided for by Section 3700 of the IsWr Code, for the performance of the
work for which this permit Is luue4
❑ 1 haw and will maintain Worker's Compensation Insurance. u required by Section
3700 of Ne labor Code. for the performance of the work for which Nu permit is Issued.
My Workers Compensation Insurana artier and Polity number art:
'
Cartier: Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7hIs semiw neall not hwmpleuo lithe permit Is foram hundred dollsa(S100)
or lean)
I certify that in the performance of the work for which this Permit Is bused, I shall not
employ any person in any manner spas tone subject to sive Worker Compensation
'
Lowe of California. D.
Applicant
au
NOTICE TO APPLICANT: If, after thisCesdOau Eumptian, you Nta
Compmvmaking
of o Labor Code. you mus
become subject to the Worker's Competetion itiou W
foMwiN comply with such pmvleinas or this permit shall h deemed mvnked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem Is a construction lending agency for de performance of
the work for which this permit is issued (San. 3097, Civ. C.)
lamer'. Name
,
Lender's Addw
I cenify that I have mad this application and sum dilute the aWw Information is
'
cortex I agrte to comply with all city and cwnty oNinancu and state law totaling to
,
building construction. and hereby ambodue representatives or this city to enter upon lie
ahvcmentioned property'ror inspection Purposes.
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilideajudgmenu. Coss and expense which may In any way acerae against W d City
In MIL
APPLLICANTCof the UNDERSTANDS ANDOf WILLWILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULATIONS.
—z! 3113joL
Re-roofs
i
Type of Roof
Signature of ApplicanVCanuactor Data
HAZARDOUS MATERIALS DISCLOSURE
Will tie appllam or future W Ilding occupant seam m'handu huardons material
efined by the Cupertino Municipal Cade. Chapter 9.13, and the Health and Safety
e, Section 15532(s)?
❑Yes t(No ,
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 os fmure building aceupant ase equipmcnl Or devices which
t huasdous air cumaminants as defined by de Bay Arta Air Quality Management
Imquirmocuts
all new materials for inspection.
rict?
❑Yu KNo
1 hew read due huardans materials lequimmenu under Chap tar A 95 of the Cali for
lfoal"SafctyCodc, Seclou25505,25533 and 25534. 1 undeaund thmiflac Wilding
s wt cuncmly law a mount, Nat It Is my responsibility u tardily the occupant of the
which must W met prior be issuance of a CcrtiBcau Of Occupancy
Signature of Applicant Date
�� -� A3&06
All roof coverings to be Class "B" or better
Owner or authonmd ager a�