04020166 f CITY OF CUPERTINO "h• ""` ms's='.+ • """'`"" '�' ^�`' ' '°'
BUILDING DIVISION PERMIT CONTIPACTOR'INFORMATIONi.,
BUILDING ADDRESS: WATER SYSTEMS PLUMBING PERMIT NO 04020166
10725 AT.DFRRRnnK T,I\T
OWNER'S NAME: PERMIT ISSUE DATE
CHOU YEONG-FENG AND FLORENCE H�R44 RFPPNFR TAT n'7 /?7 /9nna
NE: SANITARY NO CONTROL NO
(408) 266-8222
ARCHITECrrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONnsed ad,p DECLARATION
1 hereby arum ma I atn nmmaea aver Provlatom mrcn.pmr 9 ammmmang Job Description
Min Section 70110)of Doebomm 3ofthe BUat arM Profesdom Code. dmy license e �n 4961 X12. intent eOal.Gk5 $ � REPIPE FONAL��
z Lmenm Cl ^1 V4 Co.g
't„'J' Data\/ s 1 TT°A�TECI'S DECr A ION
I undenland my plant shall be used ie records AUG 16 2004
a Licensed Professional
i3 OWNER-BUILDER DECLARATION BUILDING
I 1 hcmhy mRrm that I am exempt from N°Contractors License Law for the
i mO following reason.(Section 7831.5.Business and Profession Code:My city or county
9 which requires a Permit to construct,altar,improve,dcmollab,Or manor any structure C a S n n
In Primto lu issuanee.alsomilmos tMappheent rurimell rmrw file asigned slaument
mm<
that Wis licensed functions to the provistomof the Contractors ll¢nth Law Charter 9 Sq.Ft.Floor Area Valuation
�F$ (commencing with Section 7000)o(Division 3 of NC Business and Profcnslom Code)or
that he is exempt thmafrom and du base for the alleged exemption.Any violation of
Section 7 031.5 by any applicant for a Permit subjects the applcant to a Civil penalty of 3 @L?HM lber 0 0 Occupancy
not mom man 0w hundred dollars(5500). P Y
0 1,m owner of me pmpeny,ar my employees wise wages m Iheirsole compenudon.
will do the work,and the swctum¢notlnmMtd m oRerW forule(SCC.70s/,Buarrss I
and Professions Code.The Contractors License Law does not apply w in owner of Required Inspections
literarywho buddsorimprovas thereon,and whodoessuch work hinuelforduuugh his i
most employees,provided Ihatsuch Improvements are not intended oroRere t forsam if,
however,me have uimprovementg float edict oneyearofmprovefn,meowner-
Wilder will haw de WNcn of proving mat he did nth lasold or improve for purpose of
saleJ.
0 1,m awaer of the propert,am exclusively contracting with licensed convectors to
CMISOUCl the pmjcn(Sec.7W.Business and Professions Code:)The Co minor's Lt. '
come law does not apply m an owmr of,empeny who builds or impmws Merton,and
who contracts for such pmjcm with a conlnMas)licensed pursuant w the Contractor
License La .
O l em ex map under See ,B&P C fm this mean
Owner ate
WORKER'S COMPENSATION DECLAR-11ON
1 hereby,allies under pemlty of pmryry am of the following declarations: I
I ban end will munuin a Ccriifinu of Consent self-imure for Wmkces Compen- 1
swoon,as Provided fm by Section 3700 of me Labor Code,far the perfermousee of the
work for which the permit is Issued. -
0 1 haw and will maintain Watkers Compensation Insuranm,as required by Section t
3700 of the Labor Code.for me perm once of the wide for which this permnulssued.
My��`Wok,e,CamyPeryLadon amvand Pobry number am:
Cesr�/ s�/�2 ___ Poliry R06yR�72%6A1
✓ CERTIFlCA_OFE, PI I. FROM RK
COMPENSATION INSURING -
(lbissecu°nraced not In completed If the permit is forme hundmddolli m(SIM)
or Icss) -
1 certify drat in the performance of the work for which this permit 4 issued,1 shall not
employ any person in any maintains ss to becomesubject to the Workers'Comrcia oon -
Laws of California.Do-
Applicant
NOTICE TO APPLICANT:If,after making mu Cemruate of Exempuon,you should
became subject to me Workers Compcmauon pro.ouom of the Labor Code,you must
.Jz foMwith comply with such provision or this permit hall be deemed mvokcd. '
'Z O CONSTRUCTION LENDING AGENCY
M Ihamb aRrm that dmmu a eomtmcd"n lending agency for F Y S gmay performance of ,
C dte
W Q rk for which mu remit u issued Sic.39 ,Cw C.)
ende r
Name
z Lenders Ad -••
U Q 1 comfy Nat I have read this application and sum that the shout Information u
ly fir colonel.1 agree to comply with all city and county ordinances and sum laws relating w
p C.) building convection.and hereby authones representatives or this city w enter upon me
r fad above-mentioned property for inspection purposes
Cn (We)agree Iota indemnify and keep harmless me City of Cvacmno against
to incouncil dgmc ts,c andexpe whuh may in any way accrue agaimtsazd City �
(„),z, m council a Ung a! I. `
VC
r. SOULIC D NS D WILL COMPLY WITH ALL NON-POINT Issued by,: Date
/ 1 C i Re-roofs J I
gnazura of AppliaHAZARDOUS MA> LS DISCLOSURE Dam Type of Roof
Will lhcapplicantor future huddle upant atom or hoMk imcsdom ma¢risl
as defined by the Cupertino Mamemal C Chapter 9 12.and the Hca11b and Safety
mm.Sa0y.2ssuan All roofs shall be inspected prior to any roofing material being installed.
Ym �No
1 If a roof is installed without first obtaining n inspection,I agree to remove
W01 me applicant or ins budding mupaBi use Area Quality or Mara which g P g
indnus air conummagggn(ggss������as defined M1y the Biy Ama AIr Quality Managcmcnl all new materials for inspection.
Millet? btu
I haw read the hmardu l aunalsrcgmrcnrnu under Chapter h.95ardeCaliror-
maHmlth&Sarmy Code, 8 ,25533and 25534.1 umderamnd thaufthe bwldmg
does not culocn0 t,th —u my respammdmy to cry the scup t of the
mytommm�ts a rw�s�nnC\ camoraryb� Signature of Applicant Date
owner a I vad scat Q� Dam' All roof coverings to be Class "B"or better
- Community Development
10300 Torre Avenue
°✓' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
11 t.
JOB ADDRE$S:1012 � A 0,cer6ok 4ju. I PERMIT # oto r
I OWNER'S NAME: _ I PHONW $�(19;L- 0q4 �f
GENERAL CONTRACT tUr gt�rA jw�A FAX#
I am not using any subcontractors: 2 p
Signature Date
Please check applicable subcontractors and compl a llcwing information:
® SUBCONTRACTOR BUSINESS NAME I BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
( Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
I I
Landscaping
Lathing I
I I 1
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper I I I
Paving I I I
Plastering I I I
Plumbing
I, Roofing
Septic Tank I I I
Sheet Metal I I I
Sheet Rock
Verjontracto 27 /a S' e Date -
CITY OF CUPERTINO c) ' oa o ( G
REPIPE/SEWERS/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN # 1 0 1 b ?j — I Date: I Z7 ( b�c 1
Building Address:
W795 P-Oer� rook
Owner's Name: Phone#:
m �� �a9
� . e�
Contractor: Phone: License#:�Q67
UuLAev SAS+�,�S ����,� 6 -R a 1
Contact: r hone: Cupertino Business License #:
m ; ke- l oy-r) g�iv� _ bcl� `I�
Building Permit Info: 1 1
Bldg ❑ Elect ❑ Plumb U {I
Job Description: R£ P I p�
Residential C rcial ❑
Cost of Project:
I /�
ty. if
Ap licahle Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING 1
BPERMFEE Bldg. Permit Fees BUILDING 1
A BPFIXTURE Pblg. Fixture PLUMBING 1
BPWSVCS Main Water Service .¢ PLUMBING
BPSEWER Sewers PLUMBING
`! BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING 1I
l