02020024 OF
CIBUILD NIo DIVISIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
11153 WILKINSON AV 02020024
OWNER'S NAME: APPLI ATION UB DATE
•:
KEXIH XU 02706 2002
PHONE: SANITARY NO. CONTROL NO.
OW m0 o ARCHITECTIENGINEER: BUILDING PERMIT INFO
E m❑ BLDG ELECT PLUMB MECH
Q�u CJ -- I_7 C1
LICENSED CO CTOR'S DECLARATION
lnereb rfi t i ddaneer sena Job Description
Q i_o Y a lips Iqr n # provisions n pmr 9lcommcncing REROOF . p
FHFw with Section 7000) t Basinessani Pamess sCyode dlgr license
m f i. ran «a g 'L ' gS SHAKES TO SHAKES .
ec O Lice Linc.
Daae C ntracto L ^ (/ JJJ non '''
Lie0
ARCHITECT'S DE ATION g •Y/
C- 1 understand my plans shall he used as public records /
W.p O Licensed Professional
c.i o OWNER-BUILDER DECLARATION
ID
1 hereby affirm that 1 am exempt from the Contmcwr's License law for the
f-a following mason.(Section 7031.5.Business and Professions Cade:Any city or county,
Sd S O which requires a permit to construct,alter.Improve,demolish,or repair any structure
w6 B: prior to its issuance.arm rcquhcs the applicant fo...ch permit to file a signed sutcmer,t- -----
thatbeli licersldpstatimtoMsfprevisionsoftheContractorsLicenulaw(Chapter9 S Ft: Floor Area. Valuation
(commencing with Smimn,7, I"Division3ofthe Busiresaaal Professions Cole) i, :?ti.}'i;;a l9':'.,p7^^ '''t"�"):
or that he Id uempethckfr'a ad No basis for the alli&iJ cxcanaio8,Any violation a7 n4 J'w11.1•!�..:C,. t
-of Section 7031.5 by any applicant for a perrou subjects the applicant to e civil penalty
,of no,mom than five hundred dollars(S50(p. APN Number r,i '., Occupancy Type
❑1,as owner of the property,or my employees with wages as their We conaKo cation, 109 - FRAME
-will do ness a ori and Worse structure is not aerasintended en a feredLow for sale(Sec:t7w,-
Business
J4; 307
- -' "'-' - -
owner os and ny W ons Code:The Contractor's latero law does not apply to an 3 0 7 - I NSULAT I GAI]uired Inspections" "'" I•t','
ownwho er his own
WhoWilds.provided
chat
andvementss re notwork intended
or 601 - ROOF_ TEAR OFF
or erred U his own employees,provided that men improvements are not imended or
7ofiered for sale:'1L however,the building'--- _ et is sold within ora of -'-" --�- �-6'02'------��� - '- -- -'- -----'-----.,-----"-- - '
completion,the owner-builder will have te burden of proving that he did not Wild or ROOF PLYWOOD NAIL";•'r.
improve for purpose of sale.). 603 - ROOF BATTENS
--- -. - - .., . _ .._....-.... - --------- -- -.... _
❑L as owner of the property.a. contracting wire licensed contractors to .. - 604'" — ROOF--IN-PROGRESS ..;.. t: .
_ c
p - onsiruci the project(Sec.70A.Business and Professions Cade:)The Contractor's.,
License law docs not apply to an owner of progeny who builds se improves thereon, 3
and wetoeo scads for sucn.prajecu.with e.conua<tnr(s)licensed pursuannto the _..-_ .____.-..__-_._.. _ ...._...
Conwctars l-ic<rec Law. .. ___ ____._ __.__. ....__._-._._..__. ..-..__- _. _...
❑I amexempt under Sec.' ' _ .B&PC for this reason
Own 't 'Dam
- WORKER'S COMPENSATION DECLARATION
>. I hereby affirm under penalty of perjury one of the following declarations:
l ❑ I hava and ill"maintain a Cenificme of consent m self--insure for Worker's
Compensation, as
-pmvided-for by Section 3700 of the labor Code, for the
pciformance opine work.for which ibis permit is issued;
_- ❑I had`and will mainmiti Workers Compensation I cpp���sF�tti�p66�jr{d by
3700 of the labor Code fo(the perm
forance oft�eo(oAn4eN Nis tIs
s d MY�No k ry'stC mpe t Ins Y 9^
C�'CrJ\.-list �'.(1�N.wIO•rpl -: / -.,.-... �f-11., �..''n�tJiS,�rS,l� t.S.!'al. ,
I: GF.RTIPICATIOA'.OF EXEMPTION FROM WORKERS'"" 1
'COMPENSATION INSURANCE a
'a 1 fnl s section need nbt be mmplemJ I tM1e permit is for one hundred dollars 's t `D )-
($100)orless.)
'lumpy thalot the ninan emer kf become
ct to
n .. d l ,J!
Compensation
anon Labny person m any m as to beta-e uh)ea to Ire'Workers
Compcnpation Lows of California.Dam '
-.Applirant. . ..
' n
Facto hould
NOTfcsObeohaisu WakesC 'pens tionpoionof'he Labor Crds.d most
Q forth xth ccomply with
. .
such Ferocious tons o this peont shalt be deemed rtvokW
^,^ t Y. !b' CONSTRUCTIONLENDINGAGLYCY
a_> I h eby fifiral that them is a constmet nn Iending,ger,y for the performance'
a _ work'forthis Permit is issued(Sca.l097,Civ.C.) '.:.,_,. .- _._..
6s Lenders Nfinem..tu: - _, .. __ -----re
r. ...._.. _.. ."-._
otitic
caw r'i Address,
V u
Icenifydbatch read this application w
state
' iletl - formi nn
g c ply with cry J county ordinancesd t t laws l tigQ• building .tarda nhyauthrt p ttiofthis cityt enter upon
W he above-mentivird n, y for inspection purposes,
2, (W)age1aet dem d keep harmless,chee ty Of Cipselptim against
M liabilities.judgments. I J expenses which
maY
inwY way acclue against. id
U;Z Cry n q c of th g.arm,rflh p 't
AI PlI A uN yTnNn AND wap,coMPLYwax L�oQ�aorvr 1e ]slued b r, Dat!
SOAR UL 1'1 lis •/. •' /1 y.
//,name IifArcIfA,oira) antmcmr It , !, - i Re-roofs
-HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant ofurore Wilding naeu,not stoico handle Aaialloua ma¢nal .Type of ROOF
refined by the Cupertino Municipal Code.Chapter 9.12 and the Health and Safety
ode.Sect on 25�d la)I t1 - )t f14C - l� a'P , �},rLl
❑y t Id` - . ._., i _All roofs,shall,be inspected prior-to-any-roofing material-being installed. -,_
I
II Will th trill t I t _ build g p t c q p t ; d 'e n n If a roof is installedlwithout first obtaining an inspection; I'agree to''remove
t hazard.s air I.hropmerav'aw defirrid by the Bay Are..Ail Guiltily Marajearent
D t,ct 1 all new materials for inspection. Applicant understands and will comply with
_. all non-point source regulations,
..I have read the hdaesdeurmmcdals re,culnuems under Chapter 6.95 of the
California Health&Solely Code;Sections 25505,25533 and 25534,1,understand that
if the,bni lding does nor currently have a tenant, it is my responsoul iry to notify the
' of the hat Is which must W met prior to issuance of.a Certificate of
'J :-'. "` Signature of Applicant Date
.. .. .
ownerarnalnpri:ea agent-„• ate- . All roof coverings to be Class "B” or better
OFF
ICE