10090054 REV CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10280 V[CKSBURG DR i.
CONTRACTOR:QUANjYUAN PERMIT NO: 10090054
OWNER'S NAME: QUAN YUAN 10280 VICKSBURC DR
DATE ISSUED:09/08/2010
OWNER'S PHONE: 4089738096 CUPERTINO,CA 95014 PHONE NO:
__j LICENSED CONTRACTOR'S DECLARATION
License Class Lic.# BUILDING PERMIT INFO: BLDG Ell ELECT rO PLUMB
Contractor Date MECH JIRESIDENTIAL�COMMERCIAL
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ENCLOSING CARPORT AREA(232SQ),NO RE-ROOF&HAS
(commencing with Section 7000)of Division 3 of the Business&Professions STRUCTURAL
Code and that my license is in full force and effect.
12/17/10-REV#I-FOUNDATION FOR CARPORT ENCLOSURE-3/03/11 REV#I ISSD
I hereby affirm under penalty of perjury one of the following two declarations:
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 Sq.Ft Floor Area:
permit is issued. Valuation:$2000
APPLICANT CERTIFICATION APN Number:36914010.00
1 certify that 1 have read this application and state that the above information is 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 save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
OWNER-BUILDER DECLARATION
1 nereby affirm that 1 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
1,as owner of the property,or my employees with wages as their sole compensation, installed 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) Signature of Applicant:
1,as owner of the property,am exclusively contracting with licensed contractors to Date:
construct the project(See.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,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&SafetyCode,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additionally,should 1 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 contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ an maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
p y y person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address-
costs,and expenses which may accrue against said City in consequence of the
'ng of this permit.Additionally,the applicant understands and will comply
.11 non-point source regat r the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.,6.
I understand my plans shall be used as public records.
Signature Dated Z
Licensed Professional