05060051 (4) CITY OF CUPERTINO
BUILDING DIVISION Pg .Cb , 9 >12AG`�'TUtt�r1F..U1i111', 4
BUILDING ADDRESS: PING LIU PERMUN005060051
WNER'S NAME: PERMITI59UEDAIE
YING LTU n .
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUIIDINO PERMIT INFO
BLDG ELECT' PLUMB MECH
�p - LICENSED CONTRACTORS DECLARATION lob Description
1 hereby affirm that I an licensed under provisions of Chapter 9(commencing
with Saturn 70(10)of Division Sof the Bue•• x Isand Profession,Cade.and my licen
in full form and effect t
x
a a l .
aac. REVISION-ADDING 60 TO GARAGE
Dam Contractor ORIG PERMIT #05030154
ARCHITECTS DECLARATION
1 understand my piano shall be used as public record.
�r
Licensed Professional
5 OWNER-BUILDER DECURA71ON
S I hereby afT me that I am exempt from the,Conlncmta Licax Law for the
n O following reason.(Section 70315.Business and Rofeations Cade:Any city or=my
$ which requires a permit he cautruc4 Jai.Improve.demolish,or repair any structure
ZSt prior to its iimena,elm requires the applicant fm such pcmil to file a signed stammam
<
that he is nmrued pursuant mum paniJamof the Coruscmt.License law(Chapter 9 Sq.Ft. Floor Area Valua 945
D (commencing with Section 700D)of Division 3 of the B mimnmd Pofaelnm Coic)or
$ out he Is attempt thmefrm and slas basis for the alleged Conception.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Family of APN Number Occupancy Type
am mar them five hundred dollars(SSW).
❑L a own of the property,or my emplayw with wages u slash sale ampmades, 37532001 . 00
Will do the work,and the Moment Is tot intended m offered far We(Son.7044.Business
and Prefesslo,Core:The Contractors stone Law dean one apply to an owner of Required Inspections
property who buildsarimpra ee thermn,snowless dausuch work himselfar through his
awn employee.provided that Rich Improvements an,notlimusind oraffered for male If.
however,the building or improvement Is sold within on yes,of completion,the owner,
builder will have the burden of moving that he did tot Wild or improve fir purpose of
sale.).
❑1,u over of see property am exclusively contracting with Beamed mnuacuses m
comtnal the project(See.7044.Business and Profadam Cade)The Contractors U.
come law dost am appy in m owner of popeny.wit.Wil.or interests memo,and,
who tourecu far such projects with.carecmr(s)licensed Pm[to to Convenors
License law.
0ImomCrqPtundoes ee. ��--� B&PCF.this on
or lit,IS
.Lam Dam
WORKERS COMPENSATION DECORATION
40 1 hereby sahm under penalty of perjury one of de fallowing decimation
❑Ih.wa wulmainwna Cemfimmafco mmxhf.luumfmworker.CMm 11,
ado.as provided far by Section 3700 of the Labe Code.far the performance of to
work far Which this remit Is used.
O 1 have and will maintain Workers Compensadon Insurance,u required by Section
370D of the Labor Code,for the performance of the work for which this permit B issmd.
My Worker.Compensation lastrame artier and Policy number ane:
Cama: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section ted tot W cemelcad iftW permll It forme hundredd.11.(MOD)
or lest)
I ceNy that in the performance of the work far which this permlt is issued,l shell not
employ anypermn In my mmner�naau�seT�yna subject l the Workers'Compcmadrn
Laws of CJifondt Date: �� CC
APDliunt .J e,
NO'I7C870 APPU .Jer making this Contrast of Exemption.you should
became subject to the worker's Compensation provisions of Oe tabor Cade,you mus
O rohwith amply With such Provisions ar this permit shell be diamond n vokcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then Is a conmtcslon lending agency for the performance of
the work for which this permit Is Issued(Sce.3097,Civ.C.)
ZLender's Name
Lenders Address '
p I certify that I hew mad this application and suis that the aWw Information It
coon.I agree to comply with JI city and many odlmtRes and wen Ice totaling in
Wiling Connotation.W hereby Rithmbe representatives of thin City M enw upon the
W aloe-mentioned popery far inspection pugmxs.
LL (We)All to ave,indemnify and lamp harmless the City of Cupertino against
,y liabilities,judgmenu,costs and expemen which may In my my stere against said City
In mmegmneo of the granting of this pastrami.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG TIONS. -
_ a ` ' .-?/S-S- ws— -Re-roofs
stDix
slgnure ofAppliaHAZARD S MATERIALS DISCLOSURE Type of Roof
Will the applicant ar future building occupmt.tme mheMk haardow mastriJ
ss darned by the Cupertino Municipal Code.Chamber 9.12.and the HeJN and Safety
do.Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yenf�Na
r If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or forum Wilting occupant sax equipment m devices which
Conk haaNna air anuminmts a defined by Oe Bay Area Air Quality Management all new materials for inspection.
District?
Oven �„i No
I have need the hvardmrs maeriaunequinemcnu underCheperb.95of the Califon
nit HealthA,SJcty Cade.Sodom 25505.25533 and 25531.1 understood thsifue building
dma not currently how a cone dal it u my mmpomibilly to noul'y to occupant of the
require�e tswhhrh most to or touaumceofa Cenifiaear Signature of Applicant Date
owba—"., /�f All roof coverings to be Class"B"or better
au�N yaleem ��