09080312 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESi: 22065 CLEARWOOD CT CONTRACTOR:TBD-TO BE PERMIT NO:09080312
DETERMINED
^>.''NER'S NAME: YUANNONG XUE DATE ISSUED:09/18/2009
. XNER'S PHONE: 4082196020PHONE NO:
,
❑ LICENSED CONTRACTOR'S DECLARATION T r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 1 BEDROOM(224SQ)&NEW ROOF
(commencing with Section 7000)of Division 3 of the Business&Professions WITHOUT CHANGING
Code and that my license is in full force and effect. (E)STRUCTURE; YES TO RE-ROOF(23SQ)&YES TO
STRUCTURE
I hereby affirm under penalty of perjury one of the following two declarations:
1 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. Sq.Ft Floor Area: Valuation:$35000
1 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 APN Number:32618028.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify,that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
co rest. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
�p aure Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasuns: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under'penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
I halve and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 505,25533,and 25534.
Sec0n 3700 of the Labor Code,for theerformance of the work for which this
p Owner or authorized agent:_-)C't 10 Date:
permit is issued.
1 certify that in the performance of the work for which this permit is issued.I shall
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,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must 1 hereby affirm that there is a construction lending agency for the performance of
fcrth,vith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address_
I �,ertifv that I have rear!this application and state that the above information is
currc:t. 1 agree to comply with all city and county ordinances and state laws relating
,,huilding construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
:rnnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point roe regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date '