05090211 CITY OF CUPERTINO e rt4 t s«'Ca �iw ,r EIEEI z" dr-"'
BUILDING DIVISION PERMIT h CONTRACTORfINFORMA.TION
.a n mt4< N7_. ..•.a ?'w .h't,
BUIL DING ADDRESS: JENNY J LIANG PERMIT NO.05090211
ER'S NAME: PERMIT ISSUE DATE
JENNY J LIAN ----1.2/22/2005
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00o LICENSED CONRACIOWS DECLARATION - O O O
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
Z wish SmMM 70M)of Division 3 of dm Business and Professions Code.and my license is
^�<y in full force and eRecL NEW 2-STORY SFDWL (2758 ' - -LIV. )
m g z License Class Lk.x GARAGE--4 2 0 t
F E Gimme,
Lic.# 4,r
wq r,' ARCHITECTS DECLARATION
K U I understand my plans shall k used u public retools
6
goy Licensed Professional
OWNER-BUILDER DECLARATION
ii 1 berehy affirm Mal 1 am exempt from Me Conuamors Liccne Law for the
i
no following maxim.(Section 7031.5,Business and Florentine Code:Any city or county
K$ which requires a Permit in common,alter,imports,demdlial.or repair any structure
°zy
prior it)its iauance,aim requires the applicant for such permit to file a signed statement
that he is licensed pursuant to The pmvisionsofthe Contractor's License,Law(Chapter 9 Sq.Ft. Floor Area Val$614912
y $ (commencing wish Section 7000)of Division 3 of the Business and Proressions Code)or
y - Net k is evempt thetefmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects she applicant to a civil penalty of APN Number OCCU
not mart than fie bombed&HAS.(5300} panty Type
❑1,uownerof6epmpcny,armyemploycuwiNw gumd irmlecompemdon, 32625044 . 00
will do the work and she swnurt u not intended oroffcred for We(Sec.704,1,Business
and Pmmsaons Code:The Convacmrs License Law data not apply to an owner of Required Inspections
property who builds or improves income.andwho ddessuchwmk himself orthrough his
own employees,provided Nat such improvements art not intended oroacred forsake,If.
buwewq Ne building or improvement is said within one year of completion,the owner" .�
builder will have th
wie burden of proving that To,did no,colic or improve for purpose of
ASIA.).
❑1,as owner of the property,em exclusively contracting with licensed eonuanms k
construct the project(Sec.toad,Baines and ny,who Wilds
Cade:)The Cs thermi.U.
acneLaw cocanot apply een with
arofpmpery.wk killsorimprove thereon.and
whocontractsLace for each projecu with acontrackrts)liamed pursuant b the Convxcors
Llec,ke Law. '
❑1 am exempt under Sec. ,B&P C for Nis tion
at "� DData2, G� �b
/O
-3�ORKER'SCOM SATIONDECLARATION f/
1 hereby affirm under penalty of perjury ane or the following dMantions:
1 haw and will maintain ACcNfiak of Consent k elf-insum for Weaker's Continue"
Sauna.AS provided for by Section 3700 of Me Labor Cade,for the performance of she
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Ivurance,AS required by Section -
3700 of the labor Code,for the performance of the work for which Nis permit is issued
My Workers Compensation humans artier and Policy number are:
Cartier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TNssection need not W completed if the Permit Is for one hundred dollars(SIM)
or Ica.)
1 certify Nat in the prfomeance of the work for which this permit is issued,I shall not
employ any Nixon in any Mauer.AS As heed sub' Im{he Workers Compensation
Laws of Califomia.Da� 's-3aL6T
Applicant I
NOTICE TO APPLICANT:If,of mg this Cenificak of Exemption,you Mould
become Subject to the Worker's Compcuetion provisions of the labor Cut,you mast
.Jz foMw'M comply win such provisions or Nu permit Nall be deemed revolted.
'Zr'0 CONSTRUCTION LENDING AGENCY
[-� l hereby Affirm Mat Wert is construction lending agency for rte perrormmoo of
tYi
the work fur which Mia permit is issued(Sec.3(Y97,Ci,C.)
W Q Lender's Name
G. Lender:Accreta
D
U Q 1 coolly that 1 have read this application and stale that the above information 1s
coney I agree k comply with all city and county colinantts and sure laws¢lacing co
V building eonumnion,and herebyamhmim mpmsentatiwsofshiscitytoenkrupnn Mc
ahovc"mentidpmpeny forinspection purposes
ti M (Wo)agree to ase,indemnify and keep harmless the City or Cupertino against
Z in
the StaBindof this awhicb may in any way acrvc against aid City
V z in cdmegancc of the granting of this p,mit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
z — 14-alit- Re-roofs
Signature of ApphcenUConlndor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building dempat store or handle huardous material
AS defined by the Cucenino Municipal Cade,Chapter 9.12,and the Tkahh and Safety
.Section 25533(a)7
❑tion ON. All roofs shall be inspected prior to any roofing material being installed.
Will rte,applicant future Wilding occupant use u
a , ment or whicht
' If a roof is installed without first obtaining an inspection,I agree to remove
pp v q 'p P
In.
hazardous air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
io?
❑tics ON.
I have read Me huarMws makrialsrequiremenss under C,Apkr .G95of Me Califor"
ealth&SafetyCade,Sections 25505.35533 and 25534.1uderemod shutiftho kilding
not currently have A Nasi,mat it is my nalausibili,k notify Ire occupant of rte
rements which must be met prior to isance ofa Cemrak df Occupuq. Signature of Applicant Date
Ownar dr h nhorived qcp mmp e2C All roof coverings to be Class "B"or better