04100087 CITY OF CUPEWHNO .,
Bun.Dlnc DtvlsloN PERMIT ��CONTRACTOR INFORMATION
BUILDING ADDRESS:
_z. '..
2333 STEVENS CREEK BLVD PERMIT N04 1 Q
OWNER'S NAME:
PERMIT ISSUE DATE
LING YANG
ONE: 10/13/2004
SANITARY NO. CONTROL N0.
ARC]IITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSEDCONTRACTOR'SDECLARATION
1 herchy affirm that I am licensed under provisions of Chapter Y(commencing U )orDivision3ofNCBusincssandProfcssionsCode.andm 1 ` JobDescri tion
with Section 7(Kkl Pov p ( p
i;;E LdnseClall force awermeL den is REVISION--IN HOUSE USE ONLY
4; ¢ License Class Lic s
I Dam Contractor NO NEW PERMIT ISSUED ORIG.
QQq ARCHITECTS DECLARATION / #04040077
�i W U I understand my plain shall M used a public records
30 —......0 Prnfcssnnal
�g
OWNER-BUILDER DECLARATION
3<II hereby affirm that I am exempt from the Contractor's License Law far the
i e o following mann.(Section 71131.5,Bu5lness and Pollesions Cada Any city or county
= which requires a Flock to ennstmel,alter,improve.demolish.or repair any structure
F VdIUaLI=R ru
Pd.no its issuance,4130 req WRa the applicant for such permit hipeasignedua,mem
RZG (bathe islicensedpuanllotbepmvisionsnf the Con tractor's Liernsc law(Cha Ier9
ac~$ (emameimingwi@Semon]11()1gnlDivision3nflheBuerassandPork-nnsCoac)ur Sq. FI. Fl00rATea
— Nat he is exempt Nercfrom and tN basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a peonit sObject the applicant to a civil Penalty or
not mom than five hundred dollars 45M).o). penaNumber Occupancy Type
❑ 1,u owner of the property,or my employees with wages az thcirxnle commercial., 3A'0009 . 00
will do the work,and the swarm is not intended or offered for sale(Sec.7Bax.Business
and professions Code:no Convectors License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employca.Provided that such impmsements ve not intended m ofrered for ale.Jr.
builder ,ill aveting ebrien of ment vinishsold heiiinot build of improve or,Ne owneo-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of Ne properly,am exclusively contacting with:)Tha Contractors
i. \
ccom Lot the es not (Sec.7G44,anowner
or and Professions Code:)The Conmmor's and whoc law dors not apply a is owner orproper(s who builds or improves thercon,sod
bah.Lown for such projects with a canraclor(s)licensed pursuant la Lou Convenor's
Liccnu Law.
❑1 am uemp(u r Scc\ P%�r sM1i rea.n
Owner
1 " COM ENSATION D[CLAR re
Ihcrchy-W
'on under penalty of perjury one of t wing declarations:
❑Ihaveand will mntain
aiaConibc4mof Coriumtoself.insumfor Workers COMP n- -
Salton,az provided for by Senium 3719.1 Of Ne Labor Code,for the performance of the
work for which this Permit is issued.
❑I have and will maimed Worker's Compensation Insurance,a rl by Sectio
3900 of Ne Labor Code,for the perfmaranee of the work for which this permit is issued,
My Workers Cnmpenation Insurance artier and Policy num her art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or less(This section need not N completed Bove permit is for one hundred unit.($(BI)
I cenity that in the performance of the work for which this fermi(is issued.I shall nm
employ any person in any manner an az to Neome subject a the Workers Compensation
Laws of California.Dote
Applicant
NOTICE TO APPLICANT:If,aper making this Chrfcate of Exemption,you should
become subject to the Worker's Compensation provision of the Labor Code,you must
.J O forthwith comply with such prnviumer or this permit shall N deemed evoked.
Z
P4 CONSTRUCTION LENDING AGENCY
CC I hereby affirm that there iso construction lending agency lot he Performance of
Gvi the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenlcr's Nam.
z lender.Address
V 0 1 ccnify that I have read his application and state that the above infonnetion is
)y F torted.I agree l9 comply with all city and county oNdances and state laws telling to
V huidingeansvvmion,and hereby entrants,reprncmmiws of this city(ocntesupon the
ho.-alice o Property for inspection purposes.
ham„ Q (We)agree to ave,indemnify and keep hermlea the City of Cupertino against
rn liabilities,judgments,coats and espensn which may in any wayattme against said CityAPPL,
V,'� ineonscyucnce of Negraming of this Permit.
a SOUR CANT U gTRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: l/ (J
Date
alum OlApplimenrConrecmr Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Dam
Will theappiicmn or fundic building necupanate monodic haysrdo m tcdal Type of Roof
ea defined by(he Cupenina p Code,ChaPmr 9.11,and the Health and Safety
Code,Scene,255320)1
❑Yes LEI N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or DOB
g occopam rte egaipmem or device,which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaardnus air terraria J by(he Bay Aea Air Quality Management
Diaries all new materials for inspection.
❑Yes - '
(have read the Nvaquirements under Chapter 6.95 of the Califon
nia Hea1(h,Y Safety Cale,Sections 25505,25533and 25534.1 and m.d that if t e budding
dins nm cu oily haw a tenant Nm it is my esponibility m nntily(N rccupant nr the
reunion w1hichmustNmctpn0 towilanccnfa CcrtiIII of Occupancy.
om Signature of Applicant Date
6ar doth°^'a agent Do All roof coverings to be Class "B"or better
e