12110031 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10325 TULA LN CON'fRACI'OR:1311.1.FIAMII:I'ON ROOFING PERMITNO: 12110031
INC
OWNER'S NAME: YUAN JACK AND ANNA 230 IIARRISON AVE DA'Z'E ISSUED: 111062012
OWNER'S PIIONE: 4088061963 CAMPRELL,CA 95908 PDONE NO:(408)687-2540
❑ LICENSED CON-FRAC'FOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT❑ PLUMB Cl
License Class Lic,q
NECH RESIDENTIAL -- COMMERCIAL rD
Contractor Date
-
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE St LAKE AND REPLACE WI711 CERTSINTE17D
(commencing with Section 7000)of Division 3 of the Business& Professions PRESIDENTIAL TI.27 SQ
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following boo declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area:0 Valuation:$16000
Section 3700 of the Labor Code,for the perfar once of the work for which this
permit is issued.
APN Number:35913089.00 Occupanq Type:
AI'I'LICAN 1'CER'1'IFICA'I'ION
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state Imes relating
to building construction,and hereby authorize representatives oflhis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the Igo DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicam understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-RUILDF.R DECLARATION RF.-ROOFS:
All roofs shall be inspected prior to tmy rooting material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following No reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the sWcture is not intended or offered for sale(Sec.7044, Signature of Applic m: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALJ,ROOF COVI.RINGS TO BE CLASS"A"OR RE ITER
hereby affirm under penalty of perjury one of the fallowing three
declarations: 11AZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilealth&Safety Code.Sections 25505.25533.and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally..should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District L will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,)shrill I Icalth&Safeb Code.Sections 25505.25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,1 must (late:
forthwith comply with such provisions or this permit shall be deemed revoked.
CO NS'IRUCNON LENDING AGENCY
APPLICAN r CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and stare laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCIIITE(-I"S DECLARATION
with all non-point source regulations per the Cupenino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date