07020052 7.
CITY OF CUPERTINO
BUILDING DIVISION PERMIT C�1�'� LG7C1Z ZUR �TI�N;,
BUILDING ADDRESS: PERMIT NO.
10690 MERRIMAN RD WELKIN INTERNATIONAL IND 07020052
OWNER'S NAME: PERMIT ISSUE DATE
FEI—QIU QI 19925 STEVENS C EK BLVD n2/22/2007
JNE: SANITARY NO. CONTROL NO.
(408) 73: -0188
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
U i= 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REVISION: FOUNDATION, PIERS, ANCHORS & HO LDOWNS.
A- in full force and effect Q '7,� I
)�z License Class tics — -/ / ORIGINAL PERMIT: 05090017
�w Datc Contractor G,,..�n �..�fr
A CHITECTS DECLARATION
'rR�
i a a 1 understand my plans shall be used as public records
)yV
U.y Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
p Op� following reason.(Section 7031.5,Business and Professions Code:Any city or county
Lr. which requires a permit to construct,altar,improve,demolish,or repair any structure
Z
In prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation
l- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $646797
L that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofN Number Occupancy Type
not more than five hundred dollars($500). 3 4 2 16 01� V
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.if,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under See B&P C for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workcrs Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Workees CompenaatioQ,law a carrier and Policy number are:
Carrier. S'hote- a!' Policy No.: ZSer (4411—
CERTIFICATE O EXEMPTION FROM WORKERS'—T
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
�.> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendcr's Name
Z Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
V) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
►'� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATiO
V_22/:" Re-roofs
Signature of Applicant/Contractor IDale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as dcftned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs:;hall be inspected prior to any roofing material being installed.
C3 Yes ❑No
Will the applicant or future building occupant use equipment or devices which If a roof i:;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent Dare All roof coverings to be Class"B"or better