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06060069 CITY OF CUPERTINO .BUILDING DIVISION PERMIT BUILDING ADDRESS: DO DUNG N PERM"N`06060069 OWNER'S NAME: PERMIT ISSUE DATE DO DUNG N E: SANITARY NO. CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO 0 0 PLUMB t� MECHD imp LICENSED CONTRACTOR'S DECLARATION Ib Description u 1 hereby affirm that 1 uFocused Focusedd under proOOSCflp visions of Chapter 9(commencing �i with Section 70(1))of Division 3 ofdte Bushmen and Professia s Code,and my license Is in full Farm noeffea INSTALL NEW GAS METER/ELECTRIC PANEL HOOKUP vat Z Licence Clus Lot.. Dam Canuamor ARCHITECTS DECLARATION j in< I uMeMnbe and my plans and As nc public rnrds O Licensed Prommimial OWNER-BUILDER DECLARATION I Wmby aRrm that 1 am mumpt from that Contractors Lieenrc Law for tiro p O following taco..(Section 7031.3,Business and Profmsium Cade:My city or county 5 3 F which mequimA•permit An Unstrue4 alcor.hnpow.demolish.w mpoir my ss ensue . $500 ,iut prior b its iasumm.abut mquims the applicant for such permit mole a signed statement < AwiW islicemed pusmmtmde,provisions ofdme Conuecunl Liccum LAw(Chaper9 Sq.Ft.Floor Area Valuation e�O (commencing with Sation7000)of Division 3ofthe Businosmd ProfessionsCore)um ,4, $ thin he is exempt mheefrom and the was for the alleged exemption.My violation of Section 70315 by any applicant for a permit subjects the Appikant to a civil penally of er u u Occupancy Type cot mote Nm five hundred dollars(5500L 0 1.u omrcraf the papmsy,w my emplayea with wow u ftk mm eompemdon, will do the work ad the swoum 4 not intended or offered fpr Win(Sec.7044,Business Required Inspections and Professions Cade:The Conbmmh mcoow Lkis Law dots t apply m an nel of q p property who builds car improves dmron,and who do as such work himsubf car through his own employees,provided that such Wprovemmu are notin¢nded woRemed formic.It, however,the building orhnprovmnant ismld within was year ofeompledon,the ower. Wilder will haw rhe burdes of proving that he did not build ar Improve for purpose of �sale�.). construct owner of ct property..Business exclusively conuecllng with: TheC contract's i. ® �® eosewct the ptaject(See.7014. excluand Prufosiase Code:)The Emitted Contracts LI- ���Y.YgO causes Law dao not apply m an owner of property who builds or Improves themon,and, who contracts for such projects was a cone mor(O licensed pursuant in Am conuacmM1 Lice.Law. []bete oar aur Sec. .BAP forthism J1 ftC Ow Oam r — 4ut 7.7 2m K TION DECLARATION ffgg ddd,,i s�yd v�A T� i hereby aOwar penalty of perjury oro of the following declemdom: p I haw and will maintain a Cerd(Immof Canmm m self-haute fw Worker's Compete 1 A Action,As provided for by Section 3700 of the LabW or Code.far the performance of wank for which this permit is issued. 0 I have and will maintain Worker's Compemadon Imuran¢,As required by Section 3700 of the Labor Cade,far the performance of the work for which this pemmlt is lewd. My Worker's Compeasatian Insurance carrier and Policy number are: Cartier. Policy No.: CER71FICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE OM3 suction need opt becomplesed IFrhe penis Is fwanc hundred dollen($100) or leu) I certify titat in the pwfprmance of the work for which this permit 4 issued.l shell cot LAw3oanYpenan in anY memcfm as hey cplgyTmOJtttto Oe Campetwtlpn , Laws of nypecu ill.Dam fi v o\ 1 A 1 AppOont Ahrfg4 A$IV I NOTICE TO APPLICANT.If,After making this Ce Mm opEtakeption.you should become subject An the Worker's Compensation provisions of the LAW Code,you muss .J O forthwith cemPIY with such provisiam w this Permit"I W deemed mucked. 'Z CONSTRUCTION LENDING AGENCY (.w bheteby.M.that them is a comrsawn lending agency for the Performance of D+> the wale for which tut Permit in issued(Sec.3097.Civ.G) - 14Q Le de' Name 0. IAMeh Addreas U O 1 cotify that 1 haw read this application and w m thin tom above information is W comes.I sora m comply with atI city And county ordinances and sum Ian minting le OU building construction,and hereby aurhodm mpmwnwives of this City to enter upon the Na above-mcntiancd paPeny For inepecuon purposes. (We)agree in Lw,indemnify and kap hom0w dm City Of Cupertino agamsr Iiabibides.judgmems.costs and espema which may in my way acne agsiwuaid City U Z in consequence of the granting of this permit. / (��� ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date b r S R — Re-roofs Si uoe of App' a/Contrm r r Us Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will dm applicant w future building occupantssam or handle haurdom material u defined by that Cupertino Municipal Code.Chapmr 9.13.and the Health and Safety Cam,section 23532(a)? — All roofs shall be inspected prior to any roofing material being installed. 0 Yea Will the applicant or future building=upon,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants a de0ned by tlm Bay Am Air Quality Management all new materials for inspection. District? 0Yes VI I have mad the MOUIOUs materials MmIANAAMS under Chmmr 6.93 of the Califor- nia Health&Safety Code.Sections 25305.23333 and 75334.1 understood dut if de building dors not currently haw a mnant,thin it u my romoseihility as notify the occupant of the m a sem m ria i aanaafsceni0c or aney6 Signature of Applicant Date b owns ormthari,<d a Dam' All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Cl OF Fax(408)777-3333 OUPEI,TINO Building Department JOB DRESS: IPERMIT # Zs:-12- A Phu o d 6 OWNER'S NAME: ! PHONE # Q _ - GENERAL CONTRACTOR: FAX # 0 - I am not using any subcontractors: aic ature Date Please check applicable subcontract rs and complete the following information 60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical 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 O r/Contractor Signature Date CITY OF CUPERTINO �m 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . :36924037 . 00 DATE ISSUED. . . . . . . : 06/08/2006 RECEIPT # . . . . . . . . . : 34754 REFERENCE ID # . . . 06060069 SITE ADDRESS . . . . . : 6522 CLIFFORD DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DO DUNG N ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : DUNG DO CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : DO DUNG N ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : •FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00 BELEC200 METERS 1 . 00 29 . 43 0 . 00 29 .43 0 . 00 BPGAS OULETS 1 . 00 5 .40 0 . 00 5 .40 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BSEISMICRE VALUATION 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 146 . 93 0 . 00 146 . 93 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ OTHER 146 . 93 MASTERCARD TOTAL RECEIPT 146 . 93 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL • alFkTINO CITYOF CUPERTINO aocm(oq CUPPERMIT APPLICATION FORM 14 N# � ,., 1I h � Date: r U Building Address: Mailing Address (if di Brent from building address): S Z z 64Ck Owner's Name: 90Phonek: L - I Contractor: r License #: Contact: Phone. -) I I-> Cupertino Business License#: Fax:1-(0 Building Permit Info: _Tel S+ez &l r b6 �—1 Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: S't��. oU _ '3 Type of Construction: Please check this box if the project is a -QDZ-9 second-story addition: ❑ ro'ect Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/ uasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V<= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backf10 PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFDCT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res AppIiance ELECTRICAL 2of3 WCITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING _r 3of3