10090150 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20686 GARDEN CREST CT CONTRACTOR:GREENERBLU JDHM,INC PERMIT NO: 10090150
OWNER'S NAME: LIZHONG TANG&SHE HE PO BOX 612048 DATE ISSUED:09/16/2010
NER'S PHONE: 4088719500
SAN JOSE,CA 95161 PHONE NO:(408)418-2000
a-- LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r- ELECT r— PLUMB r
License Class Lic.#Ll1-k(o 15b MECH r RESIDENTIAL r COMMERCIAL r
ContractorDate Zv 1 l
JOB DESCRIPTION:SIDING(160SQ)AND TRIM REMOVAL&
I hereby affirm that I am licensed under the provisions of Chapter 9 REPLACEMENT.STUCCO
(commencing with Section 7000)of Division 3 of the Business&Professions (92SQ)REPAIR.SEE PERMIT#10090089 FOR FEES
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two 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 Valuation:$1585
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued.
APPLICANT CERTIFICATION APN Number:36230050.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct.I 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section /
9.18. Date: `7 ``/ 6
Issued Irq"
Signator Date 'J/. d/C�
[] OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Date:
Business&Professions Code) Signature of Applicant:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I mus t O r uthoyid Date: /
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relatin;
for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
unman the above mentioned property for inspection purposes.(We)agree to save
inify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature Date Licensed Professional
CITY OF
III CITY OF C UPERTINO
GENERAL BUILDING
C U P E RT I N O PERMIT APPLICATION FORM
__ _�
APN# �
Date: 9/r7/100
Building Address:a 0&8� C1• P efA,n c,)1 CA (50141
Mailing Address(if different from building address):
Are Hazardous Materials being used as part of this project? Yes [--I No F141
HOA: (Exterior work only) Yes [ No ❑ if yes,provide letter from HOA
Owner's Name: Phone#-
L •zhoo - Tar + She- Ne-
Contractor:
eContractor: Phone:
FJ'J
�eL 'r t i-�Ill Fax Q,L), -
Contractor License#: qq&;j_3 v
Cupertino Business License#:
Conta t: Phone:
re L-,) Fax: S�— 11
Residential' Commercial ❑
Job Description:
Building Permit Info:
Bldg Elect ❑ :dumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
I-A, 1-B ❑ II/IIIN-A ❑ II/VI B,IV-HT,V-I3 7Wt511a t>vT
Vallion: Square Footage:
Project Size: Ex ress[ Standard ❑ Lar e 0 Major ❑
Green Building:Please complete relevant portion-)f the Green Building/LEED Checklist&attach it
to the application or if applicablf include in plan set&the sheet index.
Points Achieved:
For help,contact Build it Green at www.buildit men.or
Revised 07/14/09