05060136 CITY OF CUPERTINO
BUILDING DIVISION PERMIT * CONTRACTOR INk' RMA`CION
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BUILDINGADDRESS: JIAN CAI PERMITNO.05060136
OWNER'S NAME: PERMIT L55UE DATE
- JIAN CAI OA/1S/2005
sE; SANITARY N0, CONTROL NO.
AR CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT P B M H
30o LICENSED CONTRACTOR'S DECLARATION
4 I kmby of irre that 1 am Ilcemsep under provision of Chapter 9(commencing lob Description
with Smarm 1").f Division Sof Na Best..and Profeulam Code.and my license la
in,re 11 force mdefrcet. SFDWL-ONE STORY (30521 LIVING)
Dow clan Con« GARAGE-4311
9 Dam 75DECL
ARCHITF.CP9 DECLARATION
5a 1 understand my plena shill k used as public records
7 U
5th Licensed Pmfcsahmid
OWNER-BUILDER DECLARATION
f I hereby.Toon that I am exempt from the Canlactors License Lew for the
p 0 following mason.(Section 7031.5,Business and Profession,Cade:My city or county
$ which requires s permit to comment,altar.Improve,demolish,or repair any At Llmu .
prior in its issuance,also requires the applicant for such permit to file a signed statement
<
that he is licensed pursuant to inn provision of he Contractor's Lkense Law(Chapter 9 'Sq.Ft.Floor Area Valuation
(eommctcing wish Section 7")of Division 3 of the Business and Professions Cade)o $366419
$ Nat he .exempt tksefrom and the basis fm da alleged.1moptim.MY vlolmlan of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penshy of APN Number Occupancy Type
not mom than Ow hundred dollars(5500). _
❑1,as owner of the property.or my employ=with wages as deb ale compemadm,
win do the work and thestructure4 out intended oralrered for eae(Sec.70a,Downs, Required Inspections
and Pmfesslom Code:The Committees Lt.Law does rot apply a an ow.of q P
progeny who builds or Improves Neeson,and who does such work himself o through his
awn employes,provided Nat such improvements art not intended or offered for sale.If.
however.the building or Improvement is sold Mum.one)ean of completion.the owner.
Wilder will have the burden of proving Nat he did not build or improve for purpose of
al.j.
1.
as owner of the property,am exdusivcly ecatrmtug with licensed canummrn to
o wan de project(Sec.7044,Business and P reaudans Cade:)The Connector's Lt.
cense law does not apply in an owner of property who builds or improves dmmon,and,
who contracts pm.uxh projects with a canmsearW licensed pusumt to the Contractors --
License Law.
❑I not exempt under S. .B k PC to;this mason
Owner Data
W ^0.'S MPENSATION DECLARATION
�i 1 by sin=under Nulty of perjury ON of the following dWeratiom:
1 hem and will mountain a CenuOeem of Consent to sel6lnsum for WorkcraComPcn-
Milan.as provided for by Section 3700 of the Labor Code.for the performance of Ne
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Imurmcc,m required by Section
3700 of the labor Code.for the performance of the wart for which this permit Is issued.
My Workces Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This anti.reed oat kcompleted If the permitIs forme amdrtdd.H.(SIM)
or leas)
1 cenify Nat In The performance of the work for which Nix permit is issued:I shall oat
employ any person In any manner¢ cdn;aabject in the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPUCA r maks us Cenificate of Exemption,you should
become subject m Ile r a Compensation provision,of the Labor Code•you meat
,Q Q forthwith comply with such provisions or this permit shall W deemed rcd
vmke
'Z V5CONSTRUCTION LENDING AGENCY
[..t I hereby affirm that dart Is a construction lending agency for Na performance of
tai 7 the work for which this permit Is issued(Sec.3097,Civ.C.)
W� Q Lender's Name
Q z Lenders Addreas
U Q I ceniry that I have read this application and tum Nn the be.infomuuun is
[L F cunecL I agree to comply with all city and county ordinium;and state laws relating in
0 building mmumtion•and hereby aushori2 representatives of this city to enter upon the
Move--mil(We) oc property(hu In,nify an pucep hi
a
(We)gree a cues Indemnify and hick harmless the City to Cupertino a city g
UZ incoidequen menu,cuts md aspic PConichmryin my way acme against=a City
U',L A APPLICANT
of Ne granting of INN D WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale Ff �r-
SOURCE REGULATIONS. (J��/o
d Re-roofs
Signature ofAMli Y n nor Dam
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building occupantam or handle husrdom material
as defined by the Cupenim Municipal Code,Chapter 9.13,and the Health and Safety
Code.Seedona5532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Oras TO
Will the applicant or ruutum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
L'e It hazardous air conteminsm at dented by the Bay Ame Air Quality Management all new materials for inspection.
isuicl7
❑Yes VN.
I have mW the hmsnlnusmatedals requirements under Chapterb.95 of the Califor.
nia Health@ SafeiyCcdc,Smuon,25505,25533 and 25534.1 understand Natinhc Wilding
dos not currently haw a temm4 that It 4 my responsibility in notify the occupmt of Na
rcyalrcmeoa which must be met prior in issuance of a Carificam of occupancy. Signature Of Applicant Date
Owner or author!o enemy Date All roof coverings to be Class"B"or better
4