05120052 CITY OF CUPERTINO ;�'- "�
BUILDING DIVISION PERNIIT .t�ONTRA TORxTNI;OTiMA'iIION
BUILDING ADDRESS: PERMIT NO.0512 O 052
10620 MADRID RD
Ii NAME: PERMIT ISSUE DAIS
XIAODONG ZHAO 02/23/2006
NE: SANITARY NO. CONTROL NO.
ARCHrIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION lob Description
rd 1 hereby affirm Nal 1 am licensed under provisions of Chspmr 9(commencing
n with Section 7gK1)a(Division lof de Business and Profrasivm Code,gal mylicenm4
in full force and effect. ADD 1140 ' /GARAGE-433 ' /REMODEL 350 '
License Claa Lia"
Dm Contractor 4 BEDROOMS/FAMILY RM/KITCHEN
all uCL
ARCHITECTS DECLARATION
I undenund mY plea shall be used u Public rtcnr6s
U
Licensed Professional
5� Oat I am exempt
from
DECLARATIONontrac
a I mag .(ince that 1 1. exempt from d r CamrenCc License law for the
O O following moon. MI,(Section8131.5,Business and improve.
au cads:Any em or roomy
S which requires•issuance.shut
t u cnces the alcor.Improvepermitdemolish,fire a sig ed ummstrucou
prior WOhei itsscensedalw mquims lbevisiappon of for such permit I-come Law(Chmmcm
ggggFp< Nubeia licensed pursuant cede provisions Sof due
Buecur and Pro law(Chapmr9 Sq.Ft. Floor Area Val
ds (cat Amis xewlNScWon7000)tof he baiiion?of NCeged exeantion.M vi Code)or
Nat be ts exempt therefrom and de buns for the alleged exemption.My violation of
Secdon 7031.5 by any appfiont for.perch subjects the applluri m a civil mostly ofAppPNN beT Occupancy Type
not some dun five hundred dollars(5500). 3 7 O V 6 U 4 2 . 00
0 I,u owner atde pmpeny.w my employcu with warns u tkir mle wmpeuadon, `
will do the wark,ana the suudure is set Nmlvkd wortend foruk(Sm.]061,Buurcae R , •'
and Profeulau Code:The Commutes Lt.=Law docs Out apply m e Ulrea In an owner fir q P
property who builds or Improves durcon,andwho doeuwhwwk hinnu forlhrough his -
own employcu.provided That mh lmpmwmenu m notimmnded oroRemd fwsam.If.
however,the Wildintorimprowmenl is mid withinanc year otcempletion,the wanner- _ VY •��
builder will have the burden of proving That he did not Wild or Impraw for purpose of
ale.).
®®1,u awncr of papenr..m exclusively contracting with licensed canm m
It.Lal Ne Dtole (Sec.]OTC,Business and Pro(rssiom Code:)The Cmoacwrs And,
Ona law noapply roan owner of properly beWilde or improve daemon,sed, lr�a!•'•i^•7!N CCWW
who conmc fm ch pmjecu wiNeconwemr(s) massopunoanUode Canu.cter.
License live.
Dlama t der Sea .B d PC fw this master
D.m 6
W `S OM SATION DECLARATION
I bereb rot under pcnsity of duty amaf Ne following declarations:
I h.veaed will meinuin.CWOum Camentroself-Iuumfwworkerscompen-
-0an,u Pnwided for by Sudan 7700 of the Leber Code,for Ne performance of In
work for which this permit Is issued.
0 1 have and will seaman.Workch Campemation Iomrance,u required by Section
3]00 of Ne labor Cede.for dm performanO o(Ne wet for which Nie permit is issued.
My Workers Compensation Insurance carrier and Policy number Are: '
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThkaeWm need nwbecomplemd If the permit is foram hundred dollen(5100)
Or IeuJ
1 cmi fy Not In Ne pofier the wart for which this pewit u issued.I Atoll not
employ any person In any As nn mut )mpy s 6'ec ode ri CompemWon
Law.of CaUfamix.Dam '
APPlkanfAVE
NOTICE TO APPLICAI .a er ahst'.tlds0..unease&SIsaliren,you should
become subject ro dm oro p rivauon pmvi lou or six IOWr code you must
.J Z fonhwtth en PI with tui rovisians w Nis Pewi shall be domed revel
?O CONSTRUCTIONLENDIN AGENCY
[•+ IWmbY.ffiw Nat dem is a comurectinn lending agency for the perfow.rce of
ai
the work for which Nis permit is issued(Sec.3099.Co.C.)
QIsnders Nunc
n1• Z Lenders Address
U0 1 conify that 1 Mve mad Niupplication W aum that he aWw information is
Ip,r"" correct.I agree in comply with all city and county monanaa end ensu laws relating In
0 rV" Wildingconvection,and hereby authorize rep CROMAIws of this city to enter upon dor
Lf7 above-mentioned popeny for iupeniut PmPOWL
Lyv,LL (We)ae fa raw,inti fy and keep harmless the City of Cupertino against
„y y liabllid Lludg enu,cosu andeapeuu whit ey in any way aame.eeimI mid City
t.) soca acnes tNe erantine of Nis permit
APPLIS NT NDERS7ANDS AND W MPLY WITH ALL NON-POINT Issued by: Date
SOURCE E ULA770N5.
oZ m 5 Re-roofs
Siyuure IiondCo"Ton' Da
HAZARDOUS MA RIALS DISCLOSURE Type of Roof
Willthoappliantorfuue Wlldi =cowl nose or handle hundous mamrisi
as dWnod by the CupeNm Municipal Cade.Casper 9.11.W be HasiN and Safety
.Section 15531(x)7 �..( All roofs shall be inspected prior to any roofing material being installed.
[:3y. �Na
Will One applicant or future Wilding occupant use equipment w devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haxa dnu.air canuminams,As de0ned h Nc Ba Area Air y g all new materials for inspection.
District? Y Y Quality Management
DYuNu
ave WNe heol Agri I'm
eon un der Chapmr6.95orthe Califon
nu Hcol @S cry Cade,Secliom 255113,25373an 73530.1 untlentutd dwtifde Wilding
Jos ml ndy have a mnane dot it is nsibility m Wiry tlx:occupant of on
mquine which mug W me,prior to in isCertificate afOccupancy. Signature of Applicant Date
2 7 041, All roof coverings to be Class"B"or better o-
Ownerw h rimda cnt Dam