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04120129 (2) CITY OF CUPERTINO9(��snn yy�� x� UILDING DIVISION -- _ l✓V RAT PERMIT. •'. BUILDING ADDRESS: ABLE SEPTICPERMITNb4120129 10200z VICKSBURG DR OWNER'S NAME: - - PERMITISSUEDATE -. "XIAOLIN DU 520 REED ST. ONE: - SANITARY NO. CONTROL NO. (408) 377-9990 • ARCHITECDENGINEER ,r : , , BUILDING PERMIT INFO - BLDG ELECT •, PLUMB MECH yoo LICENSED CONTRACTORS DECLARATION UluI hereby affirm that 1 am Ulcerated under provuons of Chapmr 9(commencing " (.. _Job Description withSection]l1W)o(Divinon3of thoBwinw ad ProfrssionaC do ad myliccnm is a mfall f...ad.ffceaPROPERTY LINE Cl/0 LJ" nya License Class H .crag . qq Dam. .. Contractor ARCHITECTS DECLARATION . YY 1313 1 understand my plans shell be wed as public rttnNs i O ,�� Licensed Profcamonel .>. . .. _ /�� • . ... - -OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Comment's Liecnm Law for thel OO following reuon.,(Section 70315,Business and Professions Cale.Any city or county _ ... which Requires a Permit toennsuuct,one,tmpmw,dumnllsh,or rtpalr'any ateatme yS prior In Its iFauancc,also requires the applicant rorsuch permit to rile aligned statement - � that he is licensed pursuant to the provisions of the Conlmemr's License Law(Chapter 9 .Sq,Ft. Floor Area - " `9" Valuation $ (commencing with Section 7")of Division 3 of NC Business and Professions Code)or - ' that W is exempt therefrom and dm basis for the alleged esemp0oo.Any vuladat of - Section 7031.5 by arty applicant for a permit subjects the applicant m a civil penalty of Occupancy mI e not mom than five hundred dollars(5500). - .. p y'l p D;I;ssowner ofWproperty,mmy employee with wage as theirule compenuuon, -„ :. ' will do We work and It.swnum is net intended or oQemd for side(Sec.7014,Eastman ' Required Inspections and,Profeumne l&or The Contractor's License Law des not apply m in owner is 9 . P .. .. ._ -,. .. _ Own arty wheel,peror improvos sutherean,and who are hen d hfmulr ded ed through his however,the Nm suehimps mid within am not you for owneR, however,thebuilding erImprovement isoldwithin oro year of completion,the owner- builder will haw the burden of proving that he did mat build or improve for purpose of an owner ofthe property,am exmwfwly contracting with licensed contractors in - ko6swct the pmject(See.704E Business and Professions Cade:)The Connector's Lt _ cents Law doe not apply to an owner of property who Wilds or improve themon,ad. - whocontme;for such projecm with a coutractor(s)licensed pursuant to the Contractor) License Law. ' ' ❑I am attempt under Sec..' ,B&P C for this mason 0,.... ^ '� Dam WO SC NSA'DO ECLARATION 1 hereby drier under penalty of perjury ane of 1h ewl_hp�dedueuons: - Iham and will maintain aCenificacofConeemmself-inaum fm Worker's Compcn- - - ution,he provided for by Section 3700 of the Loom Code,for the performance of the, ...,. work for which this permit is issued. • - - ❑1 have and will maintain Worker's Compensation insurance,as required by Section 3700 Orden labor Codc.for the performance of the work for which this permit isissued. My Worker's Compensation Insurance carrier and Policy number am: .. - Carrier: Policy No.: - CERTIFICATEOFEXEMPTIONFROMWORKERS'COMPENSATION INSURANCE - (This union need not hccmnplemd if the permit islmow handeaddolhm(SIM) or lose.) I certify that in the performance of the work for which this permit is issued,I shall not , .. .. - . _ employ any penin in any manner an a to become ubjeet to the Werlecle Compensation Laws.(California Dam - --- _� Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should - become subject to the Workers Confrontation provisions of dee Leber Code,you mon - �z foMwith comply with such provisions or this permit shall be deemed revoked. „z„O CONSTRUCTION LENDING AGENCY - (-t I hereby affirm that then is a com uctfi n lending agency for the performance or CG.>-t the work for which dein permit is issued(sec.3097.Civ.Cd fA Lender's Name ]7-: larder's Address U O 1 certify that I have rad this application and stem that the above information Is (L F correct.I agree to comply with all city and county ordinances and sum laws rehting to OU building construction.and hereby authorim representative of Nis city in enter upon dee W above-mentiuned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against na fa'/1 liabilities,judgmenu,cosu and expenses which may in any way accrue agalnstsad City U X in consequence Of the granting of this Permit. t-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date S RCE REGULATIONS. 17--17-0- Re-roofs nature of Applicant/Contrumr Dau HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant Rare or le haardous material az defined by Bre Cupenlno Municipal Code,Chapter 9.11 n the Health and Safely ede,seeNOR ssml(an All roofs shall be inspected prior to any roofing material being installed'. ❑Tee [{pas on Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove IDinrieO mlt hwardous air contaminants as defined by the Be,Area Air Quality Management all new materials for inspection. ❑Yes1 have mad the haardous materials requirements underChapter6.95Ofdee Califor- aHcobh&SafetyCodc,Sccmns 15505,25533 and 25534.Iuncmand deniffdec building toes not c 0y haw a malum,that ft is my msponsi flity m nb ty the Occupant of dee m swhichmuatbemclmormissuuccafaCcrGfcamo .y ignatureofApplicant Date 4 /1-4 —A-� All roof coverings to be Class"B"or better wner tar authorive age ` Dam Community Development 10300 Torre Avenue i Cupertino CA 95014 Telephone(408)777-3228 OUCITY OF Fax(408)777-3333 PERTINO Building De artment JOB ADDRESS: PERMIT # to :?-bo of h r. �C4 �L© iZ9 OWNER'S NAME: PHONE # 9 p GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping, Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE Ll aTYOF �CUPEkTINO PERMIT APPLICATION FORINT APN# Date: �/ o � 6 Building Address: ,' S L Owner's Name:. Phone#: r � Do Z0 Contractor: Phone: License#: er✓t 3 0 Contact: Phone: Cupertino Business License#: Building Permit Info: 040 6 0 0 D 2 Bldg 9 Elect ❑ Plumb ❑ Job Description: r Residential 171 CorlYmercial ❑ Cost of Project: • Qty. App carile . Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING /PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i eofFixtures PLUMBING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING 7� r�-