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CITY OF CUPERTINO
CO,yNTRACTOR,INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
ZHAORONG XIA
PERMIT NO.
04020053
'ER'S NAME:
PERMIT ISSUE DATE
Z HAO
12 12
PHONE:
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 herebofy ton than 1 am licensed under prom isians or chapter 9 (rnmmencing
with Section 7") of Division 3 cruse Buri. and Professions Code, and my liccnu is
in fall force and effect
NEW 2 -STORY SINGLE FAMILY DWELLING
License ClassLia g
Data contractor
LIVING SPACE 3245 iB OURN,605 SQ. FT.
ARCHITECTS DECLARATION
f tl �`B
1undcmanJ my plansshall he used as publicDECLARATION
rtrnrN
LL,y �I
DEC 1004
Licensed Professional
OWNER -BUILDER DECLARATION
Li law for the
1 hereby aff m unit I am exempt from the Contractor's cense
following season. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to ennswel, slur, improve. demolish, nr rtPat, any slmemre
Sq. Ft. Floor Are
V""o00
priormire issuence.aNu rcquins dm applicanlfar such pcwilto Bleasigrcd stsumcm
Ce Conmetoh License law(Chapmr9
alo Ce provisions of
thalhc islieenud ptusum
(stommenciag with Section 7000) of Division 3 of the Businev and Profusuns Csde)rn
AN
thm he u exempt therefrtsm and the beau for the alleged cmmptim Any violation of
Section 7031.5 by airy appltant for • Permit subjects the applicant o a civil penalty of
APN Number Occupancy Type
oat mom Nm five hundred dollars (5500).
32630078.00
❑ 1, as owrmr of the proputy. army employees with wages as their tole campensstiw.
Required Inspections
q P
will do the imuk.snd Ceawclure is nal intetbcd orartcrW fmsalc (Sec.70l4, Busiticss
and professions Code: The Conuaaoh License law does not apply to Owner an owr of
property who builds or Improves thereon, end w ho does suc h work himul f or through his
ownemployeas, provided Nat such improvements art notinmbsil..ff..E forsale If.
however, the building as improvement is sold within one yeas of completion, the "net'
builder will have do burden of proving that he did Out build or improve for purpose of
sale.).
la
lc(1 Las Owner or the property, canuaciin with ed awuamnrs m
.
:) Th s
and l Code:) The Cs
3nstmct the Profen (Sec. 70x4, . B sines nil
rry whtimm
mer oa
clan and.
cease taw does not apply an owner of property was builds or improves Cercus. and .
who contracts for such protects with a canlnetortU licensed Personal hethe ContraemYs
c
Lkense L,
01. Pt under Sea :B&PGT rusmamn
�� Dare S a
WOR 'SCOMPEhlSATIONLaCLAN
1 hereby alBw unhr penalty of Perjury arc of the awing declmtiom:
❑thaw and will of ConservtoCode.furefm Wofkeunce
faibin•Certificate
Of o
ration, providedhhi for Section 3700 of Ce labor Code, for Bte pesfowetee of Ce
mi
work (or which this pewit is issued.
r
0 1 have and will maintain Worker's Compensation Inmnnce, as acquired by Section
3700 of Ce Ichor Code, for she Pcrfawasme of IM work far which this Permit u Issued.
My Worke(s Compensation lnmrsnce canner and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
-
COMPENSATION INSURANCE
(Mis section need not n<comp Ieted Bits, the f ermit Is formic hundmd dollar (S 100)
or leas.)
1 certify that in she performance of Cc walk for which this Permit u issued, l slaul not
employ i ny parson in any manner m as b become subject in Bre Wmkcrs' Compensadon
Laws of califomis Dau
Applicant
NOTICE TO APPLICANT. If. afar making thu Cclufrcate of Exemption, you should
become subject to the West Compensation provisions of Cc Laws Cods, you most
y fons,th comply wit such provisions or this permit shall he deemed revoked.
nCONSTRUCTION LENDING AGENCY
I hereby arllrm Cat them is a construction lending agency for the lerfurromm of
> the work fm which this pewit is issued (Sec. 3097. Civ, C.)
Lender's Name,
lender's Address
1 certify Cal I have rod us. application and sum that the above information is
correct. I ague to comply with all city and county aNisco ms and sate laws relating to
rour Ce
this airy to
Wilding(We)
ago
ahovcmentiancd pmpany, for inspection Purposes.
City against
and hmp harmless t e or erton
., to, .. indemnify keep
(We,) agme to sew, and
�
expen w Against s
n Iiabilitles.lu06menu.coats and cape"vs which may in any way aceruc against said City
Z in conscqucace or Ce granting of this Permit
—a APPLI ANT UNDERSTANDS AND WILL COMPLY AL%7N-POINT
Issued by: Date
SOU ULATIONB.
Re -roofs
Type of Roof
ignaruseo man contractor Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aceupanutore ar hasdle hrandes s material
defined by the CapeNno Municipal Code, Chapter 9.11. and the Health and Safely
. Section 25532007
All roofs shall be inspected prior to any roofing material being installed.
0Ya Nu
If a roof is installed without first obtaining an inspection, I agree to remove
or future building equipment or devices which
Will the air
-
for inspection.
by the Be,use
cmit hazardous air conuminants as fined by the BAma Air Quality Managcmcnt
comer
all new materials
District?
Yu
1 have mol Ce harndmsmamrialsrcquiumenrs under Clupur G95 of the Califer-
nuHeslC & SafelyCade, Scedons 255(15.25533 asci 25534.1 undcrsland Cuifthe building
docs tote d have a tenant Cat it is my responsibility w notify Je pant or the
Date
regmmmea ,hmaAbcmpdrB,isseaanceahee morocco'%
SignatureofApplicant
�! D
All roof coverings to be Class "B" or better
Owner thoriud agem Dam