03080114 CITY OE CUPERTINO
BUILrnNc DrvfsloN PERMIT COATRACTOR IlYT l7RMATION.^
• 4,
BUILDING ADDRESS: PERMIT NO0 3 0 8 0 114
10551 SANTA LUCIA RD
111111 NAME' - PERMTTLSSUEDATE
' JOSEPH JIANG 10/29/2003
PHONE: SANITARY NO. CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
:oo LICENSED CONTRACTOR'S DECLARATION
i I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description
with Section]def of Division J of lac Business and Prefcuinns Codc,entl my license is FINALED
mmumme ad effect. ADD 591 ' SQ. FT.
ZLicer�Claes Lic.p
i t-aDam Contractor
e ARCHITECTS DECLARATION
Cas Iunderstand myplans shallheused aspublic records DEC 2004
eau
e0t; Licensed Professional
s I OWNER-BUILDER DECLARATION
<S 1 hereby affirm Not I am exempt from the Commelor's License Law for the
O O following rcamn.(Section 7031.5,Business and Professions Code:Any city nr county
5 m� which requires a Permit m construe,slim,improve,demnlish,or repair any structure $66428
-¢ B11 LDING
a prier to its issuance.also requires the applicant for such permit to rile&signed statement
�G that he is licensed pursuant to the provisions of the Contractor's License Law(Chaplet 9 Sq.FC.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or 34217081 . 00
3 Net he is exempt themfrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by say applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more than Eve hundred dollars($500).
❑1.as owner of the property,or my employees with wages u their sole compensation,
will do the work,and the structure is not intended or offered for sale(See.7W.Business
and Professions Code:The Contractor's License Law docs not apply m an owner of Required Inspections
pmpeny who builds or improves Nemon,and who does such work himself or through his
awn employees.provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is said within one you of completion,the owner- .
builder will have,the burden of proving last he did not Wild or improve for puryose or
sale.).
I.
as owner of the property,am exclusively conducting with licensed contrsctars to
on tinct the project(Sec.7044,Business and Professions Code:)The Corr actor's U.
rue law does not apply to an owner of property who build&or Improves Nertan,and
who contracts for such projecta with o contractor(s)licensed pursuance the Contractor's
License Law.
❑lam axe oder Site BA,PC for Nis re n
One else o
�WORUMSCEWENSAM ,
I hereby affna under Penally of perjury one of the following declarations:
❑1 haw and will maintain a Cc,ifcade of Consent to self-usure for Worker'.Compcm
cation,n provided for by Section 37W of the Labor Code,for the Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the Performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one hundred dnilars(SIW)
less.)
1 certify that in the performame of the work for which this permit is issued.I shall not
employ any person in any manner so m to become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making his Cedificate of Exemption,you should
become sohjeet m the Woher's Compensation provision of the Ulm,Code,you..at
z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
Ys the work fur which this Permit is issued(Sec.3097.Civ.C.)
Q Lender's Name
z Lender's Address
J 0 1 certify Nat I have read this application and sum that he above information is
L Pconed.I agree m comply with all city and county ordinances and state laws mooting to
U building conswction,and hereby aulacrim representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
h liabilities.judgments.costs and expenses which may in any way accrue against said City �J,1
J Z in consequence of the granting of this permit (J (7
APPi UNDERSTANDSJAN.D WILL COMPLY WITH ALL NON'P NT Issued by: Date
S RC EGU TIONS
o3 Re-roofs
Si ca
HAZARDOUS
AZA ppliceD z D m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theapplicantur forum building,ccupantscoreor and the
Health and Safety finctl by the Cupertino,Municipal Codc,Chapter 9.11,and the Health and Safety
� rSOtYcs 25532(.)7 Nn All roofs shall be inspected prior to any roofing material being installed.
Will he applicant or future building occupant are equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
trait hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
DislricR
❑Yes XNu
1 have mad the hmallous ro mrisls requiremcnu under Chapter 6.95 of the Califor-
meHcalthieSafctyCede,Sections 25505.25573 and 25534.1 understand that hurt building
does not toy have a mnantth it is my rmsponihibly to nullity the occupant of the
rcquim en Nchmustbcmm «of acamficmorOceppancy. Signature of Applicant Date
Owner ser&mhoand agent
Data All roof coverings to be Class"B"or better