01020048 CITY OF CUPERTINO
BUII.DINO DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT Na.
21905 SAN FERNANDO 01.020048
OWNER'S NAME APPLICATION SUIT DATE
XIAO—RAI GU 02/12/2001
PHONE: SANI'1'ARYNO. CONTROL NO.
C ae Z ARCHHEC(ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
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t¢h
osy- LICENSI?D CON'TRACTOR'S DECLARATION
"—c "arch,tdrirnt.bat lam li,en.ed under pnivilkonal Chapter 1)(enmmnnein8 Job DescriptionGHf-J
..,It Standen 7000)nlDi,'Won 3ofthe Busincsaml lhofasicas Cde,and try license
is in full force and effect. DEMO
z a Lieaa.e class L'ie.x
a.U Date Contmmor
3 u t ARCHITECT'S DECLARA'T'ION
C t=' 1 i nd,nand tnY plans.shall he used use public reconk
va�}.-.
w O O Licensed Prnfcuiowl
OWNERBUILDERDECLARATION
v1=an I hatch, em
hy onion.hat I esmm npt frothe Contraclnn',License Law In,the
t z fallowing reason.(Section 70315,Rumness and Pndc,sions CNe Any city m musty
'x❑ which reyuims a rent...uo conamet,al.cr,improve.demolish,or repair any structure
i3m prior to it,issuance.at,.reyuims the applicant for such pernftIn file a signed slmcmenl
that he is licensed pursuant m the provision,of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
Ponn...aming wilh secfnn7000rof Insist....3 of The Business and Pon .lens Cudc)
or that he is cmmpt betatron and the basis Lor the alleged escmp.inn,Any violation
of Section 7031.5 by any applicant lou a permit subja.s the applicant uo a civil penally
arum Inane than ase hundred daua,(5500y APN Number Occupancy Type
❑1.m ov ncr nnM property or my emplayces with wages as their side mmpen,atien. 3971 ,9014r— GALA
will de the work,and the stmcmre is not intended on offered fm sale(see 9044,
Bu, and pod.... m cede:'Tbc Can(,actnr a Lia vc l,aw ane .a.apply stn Required Inspections
Rusin...
or property an build,or minuses themmn,andhitdoes such work himself
on;ough his own employee,.pro,ided mal such nor...counts are ant intended o. NO ASSIGNED INSPECTIONS
lificard Blw Obll' g_ p 1ddwase. ec
mnpl e the n n Ie. II h the burden f proving tht h did not nyeild or f
for n mo r. 1 )
as carrier lithe
ons. t property. I lycontracting II'I dcontractors n
oTool.,r IS ](44 Business d fc:.. CAr:) li t saI 1 t I Ppe ty h builds Pnv:fu r n,
and woo contract,far sort p JnR with o contractions) licensed pursunr to the
Contractor's
S
License L.aw.
OX 1.tm ee�}� +ea._�> x ser rc hand'rea.on r
OxI ORKER'S C[ UI:C ARA'I0f O/
I I hereby alrimt umlcr penalty of penury one nl'Ihe lidlewing Jedamtinm:
D 1 have and will n ain.ain a Cullfcum of Cnmentlo self-inaw'o far Work,,,,
Compenwtiorr as provided for by Section 370() of the Labor CNe. In, the
performance(if[lie work for which this pemtit is issued.
❑L have and will mainmin worker,Compensation Imo orce.as rryuined by Section
3700 of the Labor Code.fir.he perfommnce of.lie work for which this permit is
caval.My Worker's ConiRTsalino Insurance carrier and Policy rainier are:
Carrier: Policy Na.:
CEIfIIFICA'1'ION Op EXEMPTION FROM WORKERS'
C.MIPEN9AnON INSURANCE
(Phis wain i need nal be cetnplocd it he croil is I'on ane based.[dollars
IS 100)or It
I terrify ma.in.he pe,Iranmtec of the work for which this permit is I..uW,I
shall nal monis,any Person in any tnanncr se.as et heconte aohjm m The Workers'
Compenutifin Low,of California.Dale
Applicant
NO ICE TO APPLICAN'1.It.slier necking this Certificate of(Lel n)linn,You should
occur.subject o the worker's Compcnsa.ion provisions of the Labor Cade.You mots
Q Q forthwith comply with such provisions nr this peron,shall he deemed revoked.
f ^ CONSTRUCTION LENDING AGENCY
a } 1 hereby off nn that there is a comwtia
cn lending agemy fa the pece
rforman
:z7 nl'the work It,,which this fermi.is Issued(sce.3097,Civ.C.)
L ❑ Lender:Name
Z) z Lender's Address
1..1 0 1 certify that I have read This application and state that the arrive Inlimnation is
lis. E., cornet..I agree to comply with all city and county ordinance,and state laws relating
QU ,,hand mg.....actiemnnsI hereby nulhorieropmsenottivesof thiscity to ether upon _ -
} rJ] the tdannotatedpnl nyl peau nprp:.
0. (N ) glia to se. do fy Nk ph 1_,4he City rC penino against
fp Tahllt : jud,owns.riu,and c,,cows which nay n fury way arlivesatins said
U z City tnttm,cqucncc nl(he gnanfn,ol this perms.
nPPLI INUERSTANDSAND WILL.COMPLY WITHALL NONPOINI' Issued b Dule� ^
si stare o nppfieamvenn,mcu n - nate Re-roofs
HASARutors MATERIALS tstra,OSURE
wu1 the impucent m Muni ipal tto.e.Chapter
smreor and
t e Iwmnlca and
Type of Roof
as defired Sa,by the Cupertino Municipal Code.Chapinr 9.12,and.hc Health nnJ Safely
Calc. El yen 255,12(x)'! O No
All roofs shall be inspected prior to any roofing material being installed.
Will.heapplicam or fumrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection. I agree to remove
emit h:vurdous air conioninanls n,delloed ny the(lay Arca Air Quality Managc neon
District! all new materials for inspection. Applicant understands and will comply with
oyes ON. all non-point source regulations.
I have read the hazardous materials requlrrntents under Chapter 095 of the
California Health k Safety Code.Sections 25505,25533 and 25534.L understand that
I I'tbc hu holing Anus not catrrently have a tenant,that it i,my mspttnfihinny to unity the
occupant nl the rc......neral,xhiab tam,be onen prior to i..uancc of a Cenificato of
ac°I'" 1�� _p m/ Signature of Applicant Date
o.-nermamnaaaedd,amt Dore All roof coverings to he Class "B"or better
OFFICE