12100047 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10673 JOIIANSEN DR CON1'RACI'OR:CIIEN'S CONSTRUCTION PERMIT NO: 12100047
COMPANY
OWNER'S NAME: ZHUGE OF PAN FAMILY TRUST 10349 LF.OLA CI'AP I'I DATE ISSUED: 10/082012
OWNER'S PHONE: 6503530376 CUPERTINO.CA 95014 PHONE.NO:(408)726-2956
❑ LICF-NSI?U CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT❑ PLUMB 0—
License
License Class Lic.k r r__1r
1IECt1 RESIDENTIAL COhfAIERCtAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RI?MOVE EXISTING AND REPLACE WITH COMP
(commencing with Section 7000)of Division 3 of the Business&Professions SI IINGLES 20
Code and that my license is in fall force and effect. SQ
hereby affirm under penally of perjury one of the following heo 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 perfommnce of doe work for which this
permit is issued. Sy.Ft Floor Area: Valuation:$9000
APPLICANTCER IF1CATION
I certify that I have read this application and state that the above int'ormation is APN Number:37537063.00 Occupancy Type:
correct.1 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 to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of flic
granting of this permit. Additionally,the applicant understands mid will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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-RUILDER DECLARATION -
hereby affirm that 1 am exempt from the Contractor's License Lan for one of RF--ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material beteg installed.If a roof is
I,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) .
I,as owner of the property,am exclusively contracting with licensed contractors 10 Signature of Applicant: Dale:
construct the project(Sce.7044,Business R Professions Code).
1 hereby affirm under penalty of perjury one of the following three ALI,ROOF COVERINGS TO BE CLASS"A"OR REITER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's DAZARDOUS MAT'ERIAI S DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Itealth&Safely Code.Sections 25505,25533.and;5534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.1_and the Ilealth&
Safely Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,l shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption.I llealth&Safety Code,Sections 25505.25533.and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent:
.Date:
APPLICANT CF-RTI FICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and slate that the above information is
correct.I agree to comply with all city and county ordinances mid state laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ Q
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCIIITECI"S DECL.IRA TTION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional