03080046 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO03080046
21837 MONTE QT
OWNER'S NAME: PERMIT ISSUE DATE
YUAN PENG ZHANG 08/11/2003
NE:
SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O o LICENSED CONTRACTOR'S DECLARATION
w I hereby affirm that l am licensed under p ovilma of Ch purr 9(commencing Job Description
?Z with5emiunJIXy))ofDivixianJofJlcBusin fpc ryCpslp,antlmylianais FINALEO
Limumf.ca err 1 WATER SERVICE
;its Liccnu Luc
o Date c.m.emr r w.d.q CONTRACTOR: R B TRAVIS
: � mi.mmlTE...il G is mimoATION FEB 10 2004
2 < understand my plain shall M teed asPdl{tic mcnrde
:Eu
e u. Licensed Professional ' w■.
=0S OWNER-BUILDER DECLARATION BU'aW1 ■/w=�
�M
<4 I hereby affirm that I am cacmpt from the Contractor's License Law far the M
-O O following mason.(Section 7071.5,Business and Professions Cade:Any city or county
e m which inquires A peon,m construct,alter,improve,demolish,of mpair any Moscmm
pin III its issuance.Alauaquimsme Applicant rotation pernot.file a signed statement 500
<
that Mislicensed pursuant Inthe provisions oftheContracmw
r'sLicensels (Chaptery Sq. Ft. Floor Area Valuatil
L�$ (commencing with Section 70f107 of Division]of the Business and Professions Code)or
�..
that he is exempt theafrom and the basis for the alleged exemption.Any violation of
Section 7011.5 by any applicant for a permit subjects the applicant to a civil penalty of Ter 0 0 Occupancy Type
not moa Nan tout hundred della.($500).
L as owner of the popery,or my employees with wages As their sole compensation,
will do the work,and the structure is not intended or offered for sale(Ser.7044,Business
and Professions Code:The Contractor,License Law does not apply to An owner of 106 - SEWER I eq rAq�, peetions
property who builds or improves theoon,and who doessmh work himulforNrough his
own employees,provided that such improvements An,not ntended or offered for reale.if, 202 — UNDERFLOOR PLUMBING
however,the building or improvement is sold within one you of completion,me owner.
builder will have the burden of proving that he did not build or improve for purpose of 301 - ROUGH PLUMBING
..to) 507 - FINAL PLUMBING
❑ I,as owner of the property,am exclusively contouring with licensed contruto.to
construct the project(Sec.7044,Business and Professions Code:)The Con ractoh Li.
cense law does not apply to an owner of property who Wild,or improves them..,and
who contracts for such projects with a contractor(s)licensed pursuant to Ne Contractors
License Law.
❑1 Am exempt under Sec. .B k P C for this reran
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby afffm under penalty or perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insum for Worker's Compem
sato..,es provided for by Section 3700 of Ne LAW,Code.for to Performance of the
W
ork for which this permit is issued.
1 have and will maintain Wmkcr's Compensation Insurance,n¢quiad by Section a
J7M of the L hor Code,for the performance of the work for which this Permit is issued.
My Worker Compensation In%,/�no catrim.di Pol" number a ,�V
�Y 4*e e eLlvr-pullc ro:L
CERTIFICATE OF EXEMPTION FROM 0 KERS'
COMPENSATION INSURANCE
(Thin amino need not W computed if IM Icroun is foram hundred dollats($100)
sr I.")
1 comfy that in the performance of the work for which this Permit is iaaued.I shall not
employ any person in any manner sat As to become subject o the Workers'Confrom ma
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Emanni.n,you should
Wcome Subject to the Worker a Compensation provisions of the Labor Chdr,you must
.J O forthwith comply with such provision or this permit shall M deemed evoked.
z CONSTRUCnON LENDING AGENCY
I Many affirm that there is r construction lending agency for the Performance of
ai
to work for which this permit i,issued(Sw.3097.Co.C.)
ft7 Q Lentict. Name
a, lander.Add.
U C 1 comfy Nat 1 have read Nis application and stare that the above informaiun is
(y boom.l agree to coaly hereby
Interim
and county
sommi aces and cute laws r upong m
DU .1bow-gconafucsiomand hammy euNon uaoses. ivu of this city mcnmr upon the
L57 above-memioned property for inspection Purposes.
' (We)agme to save,indemnify and keep harmless tM City of Carotid again,[
f4j1 liabiliuu.jud,himus,costs and expenses which may in Any way Act.against said City
UZ in cmuquencem'the gmminguf this Permit.
" APPLICA NDERSTANDS NO WILL COMPLY WITH ALL NON-POINT Issued by: Date
so Ic ULATIONS.
f Re-roofs
Si sere. pplica onracror Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store of handle hmAp our memo.]
As defined by the Cupimm,Municipal Code,Chapter 9.12,and the Health and Safety
me,Seni.n255.72(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes "IteCIL-
Will the applicant or future building Occupant use equipment ordeviccs which If a roof is installed without first obtaining an inspection,I agree ro remove
III Mnrdnus air contaminants As defined by the Bay Arca Air Quality Management all new materials for inspection.
7Diatric,'❑Yea fano
IhavemWd cMvsnleusmawrialsmquimmcnuuntarChapwr6.95oftheCalifor-H iffihSgctyCoat,Sccuun2W5,255JJud255J4.lundcnwmthmifdm Wilding
es not turmoil A moron,that it is my mapmssibility or Ne occupant or the
him en. c ustMmn oI... Ccmr..O.f c / ignature of Applicant Date
en.
agent DatarC^ All roof coverings to be Class "B" or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICECITY 0
CUPERTINO PERMIT APPLICATION FORM
APN# 326
zG C 073
Building AddressK 1 l
Owner's Name^ Phone#:
Contractor, J ` Phone z �Z o✓ License#:
o
Contact: Phone: Cupertino Business License#.
Building Permit Info:
Bldg Elect ❑ Plumb ❑
Job Description: G-�) (�
Residential Commercial
Cost of Project: 0-6� 2
Qty.
,p A Fee ID Fee Description Fee Group
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING