B-2018-1181 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1181
10826 NORTHRIDGE SQ CUPERTINO,CA 95014-0526(316 36 045) Tsan Chou S Chen&
Hsinyu Tsai
10826 Northridge Square
Cupertino,CA 95014-
5325
OWNER'S NAME:Tsan Chou S Chen&Hsinyu Tsai DATE ISSUED:07/12/2018
OWNER'S PHONE: PHONE NO:617-620-2526
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Tsan Chou S Chen&Hslnvu Tsai Date X BLDG—ELECT—PLUMB
[hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Cade and that my
license is in full force and effect. JOB DESCRIPTION:
CONSTRUCT WALL TO DIVIDE LOFT AND CREATE(N)BEDROOM
I hereby affirm under penalty of perjury one of the following two declarations: #3(1 1 LF)
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 Libor Code,for the
performance ofthe work for which this permit is issued.
n 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 fmwhich this
permit is issued. Sq.Ft Floor Area: Vahmdii n:$1000.00
APPLICANTCF,RTIFICATION
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 31636 045
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,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 Cade,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Data 07/12/2018 Issued by:Jasmine Archbold -
Date:07/12/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
folICt vo reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
�. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sea7044,Business&Professions Code)
Q [,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:07/12/2018
I hereby affirm under penalty of perjury one of the fallowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. f have and will maintain a Certificate of Censcut to s If-iuRaa 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. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements mndcr Chapter 6.95 of the
Section 3700 of the Labor Code,for he performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.f will
^ permit is issued. n maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 ccnilY that iu the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
\J shall oot employ 'Pc_.
in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by His Bay Arca Ali-Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation in ovisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLIGAN'f CERTIFICATION Date:07/12/2018
I certify that 1 have fend this application a0d 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 thiscity 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.
Signature Date 07/12/2018 Licensed