08030111 CITY OF CUPERTINO
BUILDING D)VISION PERMIT —'CO NTRACT ORII NFOR,MATI ON
BUILDING ADDRESS: ....... PERMIT NO.
21713 ALCAZAR AVE UNITED SITE SERVICES 08030111
OWNER'S NAME: PERMIT ISSUE DATE
CHIAO AND SUE CHANG 3408 HILLCAP AVE 93!29/2008
ONE: (408) 295-2263 SANITARY NO CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I ba"by Ali that I am licensed under previsions of Chapter 9(commencing Job Description
with Scathen 70M)of Diviailon 3 of the Biomass And Professions Code.and my license is TEMP POWER
is felt torce and effect 0 • - r 3
Lice I.T :c; -7
aw Lic.1 37333"
Dole , Comment, 262,
ARCHITECT'S DEcLKkATtoN
dy I understand my plans shall m used as public records
Licensed Prolamines]
OWNER-BUILDER DECLARATION
I berchy IT,.that I am except rrate the Commences Li,can.Law fa,the
following resume.(Section 7031.5.Business and Profeastans Co de:My city or county
which mfures A perand,ac cores Aun.hapseve.diiamilsh.or repair Any tom
prior in its Issuance.Arm acquires the applicant for such permit to rile a signed musical
that he is licensed .meant to ft provisions or thic Contractor's U...Le.(Chapter 9 Sq.Ft.Floor Area Valuation
he with Section 7000)of Devition 3 of the Business and Prefiessions Code)or
'at he ii exempt therefrom and the basis for the Alleged Exemption.Any violation of $500
Section 7031.5 by any applicant for a per subjects the applicant m a civil penalty of
not a=than fin hundred dollars($50Q. 35719058 ON Number Occupancy T�pe
0 1,As muser of the property,or my employees with wages As their=to compensation,
will do 0.work. ad the.uracume Is ratirtamdul or officuid(or Wit(Sec.70".Box.
d Professimis Code:Ton Coruscate,U.Law it=mft apply us An owner of Required Inspections
no,orty who buildism Ins apeems therestraind h.d..such work ledurselfer through his
own employees,provided that such improwersons we not intended oroffered fortudes.If.
however,the building or Improvement Is told within am year of completion,the owner-
builder will haw the burden of proving that he did me build or Improve for poopme of
sale.).
[]I.u owner of the property.am exclusively commuting with licensed contracuss in-
core=the project(Sec.7044.Business and Pecallinumas Code:)The Coacwthes U.
cons,Law does we Apply in..owner of property who tafliels or aprons thimem.And.
who contracts for such penitent with a cont,actoo(s)licensed pursuant in,the Connuasur'3
LIciew Law.
0 1 Am exempt under Sic. B A P C to,i1a.reame
Owner 7tAm
WORKERS COMPENSATION DECLAR,:I`ION
I thereby afflon under Newly of perjury a=of the following clealwadom:
ban and will owntam•Carnificnaz of Cassava to self-self-insure- n.far Winters.Cimpan,
0.1...provided far by Sc.thm 3700 of the Litser Code,for dm pearMaince of dm
work for which this permit is Ismail.
0 1 haw and will maintain Wor1cor's Compensation Instruchic,As required by Suction
3700 of the Labor Cod..In,the puffenowne..(the work f.r.huch this .I,is issued.
My W ryK'l Creep....a. I d Palley number are:
0
Card Lys a. No.:I.ik7rof^1DU 35 334go 17
ceprrifkmis OF ExEmPrION FROM WORKERS'
COMPENSATION INSURANCE
Crisis suctort ad act be completed ifthe Permit is(a,one hundred dollars(SIM)
or less)
I certify that in the parromearacc of the work for which dil3 Permit IS wood,I still not
employ any person in any manncrm As to become subject to the Warkirs'Comptemation
La.,or California.E---
Applica,-
NOTICE TO APPLICANT:If,after making this Cwtificam of Exemption,you should
become Subject 0 the Worter's Compicaturflon proviscom of the Labor Cafe you mind
Z forthwith comply wit such provisions or dus Permit shall the deemed rawakett
z 0
71 CONSTRUCTION LENDING AGENCY
Thar affirst that them is a commmaidne lending agency for din performance of
CL > Jm.,it far which this permit 1,issued(Sec.3097.CN.C.)
Leader's N.-
Leaders Addnw
U Q I certify that I ban rand this application aminate that the show termination is
[,, ^ CmaulL I%ApTc In Comply With All MLY and county onalmnates And send how mining to
8 SU^ building commection.And hereby auffinnic,representatives of NU city to annuities the
.1mve-noccuorecd property far impscum puniands.
(We)agree to saw,indemnify And loup m0aiia[S the City of Cupertino Against
liabilities,judgments.costs and expenses which may in any way accrue against said City
of the gr3ptaq `ZL COMPLY WITH
Appme
hc�ucncc..Ith 0 r)h ALL NON-POINT Issued by: Date
/Z"` A"r' Re-roofs ffovloc-!�Ew—, I Difte
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wil t or rut=building occupant atere in handle hownd,0113 material
as dcarand by the Cupertino Municipal Code Chapter 9.12.And the Health and Safety
Code.Section 25532(a)?
E]YEA XN. All roofs shall be inspected prior to any roofing material being installed.
NiVill the apitheart or futon building occupant=equiproacreL Of devices which If a roof is installed without first obtaining an inspection,I agree to remove
i hocanden.air...usamarts As d.flowd by the Bay Am.M,Coolly Management all new materials for inspection.
,uact?
Dyes XN-
I how rand the howelous materials requirements uncerChaptarti.95 olive cathrou,
nia Health,kSarctycodc,S000o �1 Mind toolossisaid dauffne,building
y annif
it.not contend,he.A h�'Ili,,I to notify the me.,.,of ft
requi Inch P Issuence or.cerancese or occuparicy.
Signature of Applicant Date
All roof coverings to be Class"B"or better
rMw Z�.ctrvl Dam
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35719058 . 01
DATE ISSUED. . . . . . . : 03/20/2008
RECEIPT #. . . . . . . . . : BS000004213
REFERENCE ID # . . . : 08030111
SITE ADDRESS . . . . . : 21713 ALCAZAR AVE
SUBDIVISION . . . . . . . '
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHIAO AND SUE CHANG
ADDRESS . . . . . . . . . . : 21713 ALCAZAR AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : UNITED SITE SERVICE
CONTRACTOR . . . . . . . : KEVIN MELLIFONT LIC # 742
COMPANY . . . . . . . . . . : UNITED SITE SERVICES
ADDRESS . . . . . . . . . . : 3408 HILLCAP AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95136
TELEPHONE . . . . . . . . : (408) 295-2263
® FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -- -
1BSEISMICR VALUATION 500 . 00 0. 50 0. 00 0 . 50 0. 00
1EPERMITFE FLAT RATE 1. 00 40.79 0. 00 40.79 0. 00
1ERT<200 UNITS 1. 00 40.79 0. 00 40 .79 0. 00
1TRAVDOC FLAT RATE 1. 00 40.79 0. 00 40 .79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 122 . 87 0. 00 122 .87 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
---------------- ---- ----=--------------
CHECK 122 . 87 #2562
---------------
TOTAL RECEIPT 122 . 87
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
CITY OF CUPERTINO OkO3 ow
TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
APN # 3 / G ��! Date:
";�> _ "Zo . bar
Building Address:
Owner's Name: �C,41 ko I- Phone #: C�e-k`. c,{{ru.�C�
J 6- 4-eo • --K SL4S S
Contractor: (�f Phone uco5>2�s. ZyG3
R"u�,e-C S Fax #: l
Contact: Phone #:
Contractor License #: -g�-7
Cupertino Business License #: l
Job Description: -_T- aw=
Residential Commercial ❑
Valuation (cost of project):
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>1K Res. Temp Power>1K E 1REAP14
Amps
IERT<200 Res. Temp Power<200 E
Amps
1 ERT2001 K Res. Temp Power 200-1 K E
Amps
1EPERMITFE Electric Permit Issuance E
IELCPLNCK Electric Plan Check — E -
/ 1BSEISMICR Seismic Residential B
CITY OF CUPERTINO
'45- TEMP POWER
CITY OF
. CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group Permit Type
1BSEISMIC0 Seismic Commercial B 10EAP14
IECT<200 Commercial Temp Power E
<200 Amps
1ECT>1K Commercial Temp Power E
>l K Amps
IECT2001K Commercial Temp Power E
100-1K Amps
1TRAVDOC Travel & Documentation B
Fee l
1BUSLIC Business License B
•
Community Development
10300 Torre Avenue
' -to Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
4UPERTINO
Building Department
JOB ADDRESS: PERMIT #
2-k-1 k3 A tea-7 ae ,4Jc . 0 D 3 d ( (
OWNER'S NAME: ( Z., ,TMr S t rc PHONE OR09) 224.3 1
GENERAL CONTRACTOR:0.)rrT) -:F:,,-ri FAX #
I am not using any subcontractors: k5�, A�� _ 3 /20 1C.;,-e
Signature 1 Date
Please check applicable subcontractors and complete the following information:
I ® SUBCONTRACTOR I BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical I I
( Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
( Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
•
Owner/Contractor Signature Date
I