07030120 CITY OF CUPERTINO
BUILDING DIVISION PERNIITP10
BUILDADDRESS: PERMIT NO.
IN1635 RALYA CT XINLIN QING 07030120
-.R'S NAME: PERMIT ISSUE DATE
XINLIN QING 18635 RI1LYA CT 03/16/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions oC Chapter 9(commencing
:Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD HALT' BATHROOM IN EXISTING GARAGE
a a in full force and effect.
License Class Lic.k
;Ftp Date Contractor
-a ARCHITECTS DECLARATION
7 a< I understand my plans shall be used as public records
�yU
U.y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
e (Yi which requires a permit to construct,alter,improve,demolish,or repair any structure
Z} prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
a that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 q.Ft.Floor Area
Fp (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $6431
i 3 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 of p(��Number Occupancy Type
not more than rive hundred dollars(5500). 3 7 5 2 5 0 0 E t .
0 1,as owner of the property,or my employees with wages as thew sole compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044,Business 'Required Inspections
and Professions Code:The Contractors License Law docs not apply to an owner of �l 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.).
'r I,as owner of the property,am exclusively contracting with licensed contractors to
tons
[ruct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec.
B&P C for this reason
e1 :r ✓V — Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as regbimd by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner socorge su ect to the Workers'Compensation
Laws of California.Datel l2�L
Applicant
NOTICE TO APPLICA :1,after m'gi4 this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z '" CONSTRUCTION LENDING AGENCY
(~i I hereby affirm that there is a construction lending agency for the performance of
IYi> the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
Z LcndersAddress
U C) I certify that 1 have read this application and sure that the above information is
correct.I agree to comply with all city and county ordinances and sure laws relating to
rJ building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
„Hy fn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. y Date l Gift
►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: –
SOURCE REGULA ONS.
O L— Re-roofs
Signature of App rl cant/Contractor Date Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
C.
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes [XNo '
If a roof is installed without
Will the applicant or future building occupant use equipment or devices which first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new maerials for inspection.
District?
0Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
docs 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 0c npancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or aur orized agent Date it