05120040 CITY OF CUPERTINOx
BUILDING DIVISION PERC,oNTRACTQ�iNFORMA
MIT JON
BUILDING ADDREss: JENNY LIANG/SHENG J .YONG vERMIT No.05120040
10078 SANTA CLARA AVE
OWNER'S NAME: PERMIT ISSUE DATE
JENNY LIANG/SHENG J YONG
)NE:
SANITARY NO. CONTROL NO.
ARE BUILDING PERMMINFO
BLDG EIFCT PLUMB MECH
O j LICENSED CONTRACTOR'S DECLARATION I Job Description
xC 1 hereby affirm that 1 am li¢vN under provisions of Copier pier 9(commencing P
<i with Section 7")of Division]of the Business and Prafcssiuu Code.and mylicertsc is
in full force and effect. TEMP POWER POLE
j z Lkenac Class Lic.s
=f,p Dau Contractor
ARCHITECTS DECLARATION
Im 1 understand my plans shall ed public records
]yW usu
U
o t; Licensed Professional
OWNER-BUILDER DECLARATION
f I Wrthy atTirm
that Earn exempt from the Contractors License law for the
e0 following reason.(Sctuce 2101.5,Business and Professions Cale:Any city or county
which requires a pemtit to construct alter,improve,demolish,or repair any ssnucturt $300
Sty prior¢its uuuance,aLwmquirea dmapplicant Enserch permit¢III easignodsuennom
<
that heislicensedpursuanttoOn,provisionsofineConuacterilicen.¢law(Chapter9 Sq.Ft. Floor Area Valuation
eta-'$ (commencing with Section 7")a Division of the Business and Professions Code)at
—
most he u exempt thctefrom and On Esau for Ne alleged eacapuon.My violation of
Sectirn 7031.3 by any applicasrt for a permit subjects the applic nd to a civil penalty of P U U Occupancy Type
an,mom Nan Eve hundred dollar(5500).
I,u owner of On property,or my employees with wages as thew sole compewdon,
will do the work and Ne summers is net intended or offered for mic(Sec.204.Bushous Inspections
and Profecsiru Cade:The Cnnuacwrs License Law eons not apply m an owner ofRequired P
pmpeory who builds or im proven thercon.and who does such wort hiateelf or duough his
own.,I.yes.Provided dot such improvements art rmtimendW"offered for sale If,
however.Ne Wilding or improvement Is sold within one year of completion,the owner.
Wilder will ban the busdon of proving that W did net Wild or improve for purpose of
sok.).
❑I.as owner of ct pec.7(u am sirs.send confessions with licensed contractors i-
constnrct the project(See tooa4.Guinea aM Py-volm ns Code)TW Camrvaon.Li-
counts,
OF
who Law doernot appy Pan owarorproputs)lice Wilds orimproves daemon.and, C
who License
Lace for such projects with a crntracloKs)licensed pursuant m Ne Conuanors za
Lkena ace.
❑lam exempt under See .08 PCfrr Nu ?00s
n y
Owner_ ) ._... Dem
W FR'S COMPENSATOLSRATION
1 hereby affirm under penalty o(pmjury` Ne following declarations
I bare and will maintain•CeNfutam of Consent a mlfAmmon for Worimet camper
7colmlyl
on,ss provided for by Section 3700 of the labor Code.for tW Pedam.of the
rk for which this permit is issued.
I ban and will maintain Workers Compensation Inmuvrce,as legdmd by Section
0 of the labor Code,for Ne performance of the wort for which Nis Permit u issued
Workers Compensation Insurance carrier and Policy number am:
rier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7tu section need ambe canpkted if the Permit Is for rnehundrei dollars(SI W)
or Ins.)
1 cortify that in the performance of the work for which this permit Is ummd,l shall not
employ any person in any mannersp u b become abject u tW Workers'CompcnWian
Taws of California.Date a ----
Applicant
NOTICE TO APPLICANT:If.after making Out Ccrefica of Exemption.you should '
become abject N the Workcri Compewtion provisions of the Labor Coac,you most
.J 0 forthwith comply with ash provisions or this permit shall W deemed invoiced.
N CONSTRUCTION LENDING AGENCY
(-� 1 hereby atti m Nat Nem is a construction lending agency for On Performance of
(5: the work for which this peon Ls issued(Sec.]092,Civ.C.)
WQ Lenders Name
�
=z Lenders Address
U O 1 eerily that I have rod this application and suer Nst the shove information is
jr.F correct.I ague in comply with all city and county ondirsonm and sum laws relating to
OU building construction,and hereby authorim representatives of Nu city to enter upon the
F Cmon—mentioned property for inspection purposes.
(We)agree to an,indemnify and keep harmless the City of Cupertino against
cn liabiliucf,judgments,costs and expense which may in any way aecom against said City
U Z in consequence of the graming of Nu Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date O r
SOURCE REGULATIONS.
J'�v (� a Re-roofs
Signature of AppliantlaimErm s, Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or fuure building oeeupant store or handle haallow material
At defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ale.Section 2ss]z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu ❑Nr
Will thea lienor or future Wilding occupant used If a roof is installed without first obtainingan inspection,I agree to remove
PP 6 v equipment Qu or devices;whim P g
I,ha'raNnw air contaminates u defined by On Bay Arca Air Quality Managcmcnt all new materials for inspection.
DiaicO
❑Yes ON.
1 have mad the hocaritw mauriau req unnovenu under Chopurb.95 of dm Califer-
oiaHralN6SafclyCade.Satiate 25505.2553]an11553<.l undcmwd dutifdm Wilding
docs not currently have a¢Wane that it u my mapomibilily u nmiry the occupant of tW
requirements which most the met prior¢issuance ora cmof"t,o(occuPancy. Signature Of Applicant Date
owner or authorind agent Dam All roof coverings to be Class "B"or better
Community Development
.�.�4t 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: ! S t CL PERMIT #
OWNER'S NAME: a , PHONE #
GENERAL CONTRACTOR: Y4 01.FAX # !r
I am not using any subcontractors: u
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
TEMPPOWER
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
I Do $ 4r&, AV, ,
Owner's Name: Ph ne #:
U"G , Zu qt - 697 .
Contractor: License #:
99
Contact: Cupertino Business License #:
(AN _
Building PPcrmit Info:
Elect U
Job Description: T I 9-
Residential 'j2f i Con6frierciM ❑
Cost of Project:
p O
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
� 23/ C)