10010049 REV1 CITY OF CUPERTINO BUILDING PERMITOA-rE
BUILDING ADDRESS: 10391 ANN ARBOR AVE CONTRACTOR:LNB CONSTRUCTION,INC PERMIT NO: 10010049
OWNER'S NAME: YING LONG&JEFF CHEN 1 CORTE ANA DATE ISSUED:04/09/2010
k ER'S PHONE: 4088650857 MIL BRAE,CA 94030 PHONE NO:(415)585-3884
❑ LICENSED CONTRACTOR'S DECLARATION BUDDING PERMIT INFO: BLDG ELECT r- PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD MASTER SUTI'E,STUDY
(commencing with Section 7000)of Division 3 of the Business&Professions FAM LY,LIVING(1432SQ)&REMODL
Code and that my license is in full force and effect. KITCHEN(300SQ),BATHRM(200SQ)&BEDRMS(600SQ);STRUCTU
5/17/ 0-REVISION#1,RAISE EXISTING GAME ROOM FOUNDATION,KEEP
I hereby affirm under penalty of perjury one of the following two declarations: EXISTING WALL,NEW ROOF FRAMING
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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.F t Floor Area: Valuation:$280000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:32628028.00 Occupancy Type:
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section -.80 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issu,;d by Date:
i
Q OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, insta.led without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Sign..ture of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,�J°r e
performance of the work for which this permit is issued. .L; I hai e read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as prov`ded for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safely Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall cont:Lminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Heal:h&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. Owner or<'thorize "gent:
Date: / I
APPLICANT CERTIFICATION
CONST UCTION LENDING AGENCY
I certify that I have read this application and state that the above information is -
cor ect.I agree to comply with all city and county ordinances and state laws relating I herr by affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lem er's Name
.mify and keep harmless the City of Cupertino against liabilities,judgments,
..s,and expenses which may accrue against said City inconsequence of the Lent er's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
' I und--rstand my plans shall be used as public records.
Signature / 1 Date 0
.` J / Licensed Professional