03070230 (3) CITY OF CUPERTINO �'^' .,Y -nr
BUILDING DIVISION PERMIT CONTRACTORINFORMA' IQN
BUILDING ADDRESS: PERMIT N003(]7(]2 3 0
141 RTrHwonn ng
R'S NAME: PERMIT ISSUE DATE
XIAO SHI 003
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Ip Zp LICENSED CONTRACT'OR'S DECLARATION bDeSCrlphOn
ffj 1 hereby affirm that I em licensed under provisions of Chapter 9(commencing
i� with Section 70(a)of Division 3 of the Businux and Professions Code,and my license is
in full force and affect. REPLACE
Ll F; License Claw Lic,A
III--- Data Contracts, /\
'
ARCHITECTSDECLARATION / \'
f 1underaunJ my pansshall he TSnpublicrecords
y1� LiccnceJ Professional t
OWNER-BUILDER DECLARATION
200 1 hereby affirm that 1 1. camps from the ictiCorrector's CoLicense Law for the
p o following mason.Permit
t 703 mer Business and are.Predictions Code:Any city or county
which acyuiru a permit re cnnswa,allot impress.h parent t fie A sig any tatemuac I $5000
.ti pnounits iuwnce,also requires theApplicantfor wchpmuilmienseLAW(Cammcm
¢x� thatuscies wit punuant to the of Diviner of the e0union LicenseLAWCodar9 Sq. Ft. Floor Area UBUO❑
c+p$ (comicisexemit0accdornGOBthebasisfon rnithcBcdexemptand on.Aninviodah.or 36908037 . 00
e a
that he u exempt Nertfrom and the baso far Ne alleged exemption.Any vinlatlon of
Section 7031.5 by any applicant for a permit subjects On applicant to a civil penally of APN Number O- upaney Type
not mare than five hundred dollar IM).
❑I.as owner of the property,in my employees with wages At deb sale compensation,
will do the work.and the impart is not intended or offered far W.(Sec. Business d Inspections
and Prefosiona Cade:The Character,Licence Law dors not apply i an owner of 10 2 - PIERS
prapenywho builds or improve,thereon,end whodoes such work himaelfor through his
own)mpinyou,provided that such improvements..at intended maffered forsale.It, 103 — UFER
however,the building or Improvement is cold within am year of completion.Ne owner,
Wilder will Mro the burden of proving that he did not build or improve for puryose of 104 - REBAR
ale . 105 - ANCHOR BOLTS
1 I,as owner ofJmpoeacny,amuclusivelyconractingwith licensed contraetsmlo 106 - SEWER & WATER
conswn the project(Sec.71144,Business end Profuaiam Code:)The Conmctora Li.
neaeLaw does notapply toanowner ofproperty who Wild&orImprovuthereon.and, 202 — UNDERFLOOR PLUMBING
Lie me law4 for project with eehnracmr(Olicenced pur,uamathe Conranara 203 — UNDERFLOOR MECHANICAL
❑lam exempted Sec. B A P C for this mown 204 - UNDERFLOOR FRAME
am 7/3do3 205 - UNDERFLOOR INSULATION
I WORKE 'S COMPENSATION DE ATION
I hereby affirm under penalty,of perjury aro of be following declarations: 301 — ROUGH PLUMBING
❑Ihave And will maintain a CenificamofCoastal.to cel6lnwre for worke'sConown- 302 — TUB fir. OR SHOWER
a7mn,a provided for by Section 3700 of be Labor code.fm the performance of tha 303 - ROUGH MECHANICAL
work For which this permit is issued. 304 - ROUGH ELECTRICAL
❑I baro and will maintain workers Compensation Insurance.As acquired by section 3 0 5 - FRAME
3700 of the Labor Cade,far the performance of Ne work(or which this permit is issued.
My Worker's Compensation Insurance terrier and Policy number an: 306 — HOLDOWNS
Carrier: Policy No.: 307 - INSULATION
CERTIFICATECOMPENSATION INSURANCE ORKERS' 308 — SHEETROCK
mos nation beadnol hecomplemd ifthe Permit is i.e.hundred dollars($100) 309 - EXTERIOR LATH
"rat'') 310 - INTERIOR LATH
I ccnify that In the performatee of the work for which this p),Can is issued,1 shell nut 311 - SCRATCH COAT
Cn icy any person in any meaner an as m become subjCct to the Workeri Compensation
Lawn marn of Celifomi,.Date 313 - ROOF NAIL
NOTICE EITOAPPLICANT.if.a(wmakingthlsCenificalcofExemption.youshould 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation provisions of out Law Coda you mon 502 - FINAL PLUMBING ENERGY
,D Z fonhwith Comply with such provisions at this permit hall he deemed revoked.
ZO 503 - FINAL MECHANICAL ENERGY
M CONSTRUCTION LENDING AGENCY
I hereby affirm Nal there is a construction lending agency for the performance of 504 - FINAL BUILDING ENERGY
Y> Thew.Aarwhich this permdaissued(Sec.3097.Co.Q 505 - FINAL ELECTRICAL
a7 O Lander'sName
�z Lcn&rlsAddms; 506 - GAS TEST
J p I ccnify Nansum
at I have mad dem Application d that the above information is 507 - FINAL PLUMBING
(~ correct I agree to comply with all city and county ordinances and sate laws rotating to
pU building conswction.and herebyauthorize npmsentetiroNaafNiscitytoenteruponthe FINA MECHACAL
above-mentioned property far WCPection pugoset
(We)agree 1.save,indemnify and kcep harmless He City of Cupenino againstmay in any wayacC..g.ainslaidCity
V-6
A NGJ7 in conseuenco of the greasing of this permit.APPLICANT N RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: WORKS Dat
SOURCER IONS. s /�
_ Re-roofs
tgn plre HAZARDOUS MATERIAISDISCLOSURE
ior as Type of Roof
Will the applicant or futon building aaeupam marc or handle hvANous material
u defaced by the Cupertino Municipal Code,Chapter 9.it and the Health and Safety
.Section 25533(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yet YPNu
Will the applicant or future building occupant use equipment or Jevicu which If a roof is installed without first obtaining an inspection,I agree to remove
each haamft us air chAaminants a dcRUCd by Ne Bay Ana Air Quality Meaagcmcm all new materials for inspection.
District?
El Yet
I have mad the Wool materials requircmenu under Chapter 6.95 of the Caller.
ad.Health at safety talc,&Co.25505,25533 end 25534.1 undonand that Ifthe building
thM not cu 0y Ae a anen4 Net Il is my re,ponslhility m nattily the occupant of the
mquimmen muatbCmelim.rmiuvea¢af.c.rufcamof )arany Signature of Applicant Date
�/"3
rror authorind gent Data
All roof coverings to be Class "B"or better