B-2018-0924 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0924
7747 LILAC WAY CUPERTINO,CA 95014-4208(359 04 005) WU SHUN JACKSON
AND CHIA CHU GALE
TRUSTEE
7747 LILAC WAY
CUPERTINO,CA
95014-4208
OWNER'S NAME: DATE ISSUED:05/30/2018
OWNER'S PHONE: PRONE NO:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor WU SHUN JACKSON AND CHIA CHU GALE TRUSTEE Date X BLDG_ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —IMECH X RESIDENTIAL COMMERCIAL
with Section 7000).f Division 3 of the Business&Professuris Code and that my
license is in fall force and effect, JOB DESCRIPTION:
REMODEL KITCHEN(82 SF)
1 hereby affirm under penalty of perjury one of the following two declarations:
r. 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,
1. 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.Ft Floor Area: Valuation:$49000.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and stale laws relating to building construction,and hereby authorize 359 04 005
representatives of this city to enter upon the above mentioned properly for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,Judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City In consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/30/2018 Issued by:Jasmine Archbold
Date:05/30/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Lmw for one of the R F-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. I,as owner of the property,or my employees with wages as their sole installed without first obtaining,in inspection,I agree to remove all new materials for
compensation,will de the work,and the structure is not intended or offered for inspection.
We(See.7044,Business&Professions Code)
z 1,as Owner of the property,am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project(Sec.7044,Business&Professiorn Code). Date:05/30/2018
1 hereby affirm under penalty earperjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. I have and will maintain a Certificate of Consent to self-insure An 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. HAZARDOUS MATERIALS DISCLOSURE
2 I have and will maintain Worker's Compensation Insurance,as provided far by I have read the hazardous at,,lots requirements under Chapter 6.95 Of the
Section 3700 of the Labor Code,for the performanceof the work for which this California health&Safety Cade,Sections 25505,25533,and 25534.1 will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that iu the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ any person in any nr sas to become subject to the material.Additionally,should I use equipment or devices which eni t hazardous
Witt ker's Compensation laws of California.If,after making this certificate of air contaminants as detned by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I nest forthwith comply with such provisions or this permit shall /
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05130/2018
1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City In Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
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