05050088 CI'CY OF CCIPERT[NO 7 T577,77777
BUILDING DIVISION PERMIT 6CONA
�TRCTOR INFORMATION
BUILDING ADDRESS: ]rI-CHANG WANG PERMITN65050088
2Q7 C01-P 14ARROR A-V
OWNER'S NAME: PERMITISSUEDATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
_op Lm that
I am CONTRACTORS underSDECLARATION
F❑ 1b.mbyaffirmNat1amIfon,Rounderpmvlsfosts Chapter Job Descri o�nn
lc. with Smrce 70!111)0!Diviusnlof NC Business and Pmfctsiom Code,atMmYliccmc isc. q B��Qi®
in full Tone and cffmt ��sMVp 1�'L�e1
o q L.me Class Lie.. REPLACE FURNACE & A/C
nen Dale Cantncmr
Y ARCHITECTS DECLARATION
Y w a 1 understand my plans shall le used as public records II�j
d.t; Licensed Prorc.o.inl Oi 2a`+ra
ipg OWNER-BUILDER DECLARATION p
.�0 S 1 Wrehy affirm that I am exempt from Ne Lesions o License Law for he ®A Fl�e
OO followingmassa aroma 7031.3.Business and ve dOipa Code:Any tiny or county
gy��9 Un " Ltlryt'a
which requires a permit m confit the alter,improve Permit to
m repair any ned omemum
,^Z6 thit he illienseCpursuant to to theapp
so the such permilmicensle ae Law(Chapter
that licensedpursuanttoNcpmvisioanofNCComrumssll¢nulAonsCodmr9 Sq. Ft. Floor Area Valuation-
WI-0
(commencing LSd did tho tion]and the bvision t di(be n,cBusd exemptandion.
Professions Code)of
y 3_ Nm be H eaempl Nntefmm and or bar for did alleged a plicam .Any violation of
notGo m d LS va hAny undredi dollars
for(S500mit subjects the aPPlicant m a civil penalty of 3( IguIrtle,0 0 Occupancy Type
not momlrannw<hpnemddoles,(ssao). P Y YP
o
I,as owner ornhe pmPcny,or my employees with wages As their ole comPensaion,
will do the work and the swemte is not intended or offered for sale(Sec.7044,Business
and Profusions Code:The Conuncmr's License Law dos not apply to an owner of Required Inspections
property who builds or improves thereon,and who does suchwork himself or though his
own employees,provided that such improvements arc not intended proffered formic.IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose or
sale.).
❑I.as owner of the propert,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7044.Business and Professions Cade:)The Contractor's U
cease law does not apply to m o ndr of property who Wilds or implawa thereon.and
who contracts for such projects with a eonuaetor(s)licensed pursuant to on,Condolences
License Law.
❑lam eaemptu der See. .B&PC for this rens -
Owner / Date
RKER OMPENSATIONCLARATION
I he y affirm under penalty of perjury one of the following declarations:
I have and will maintain a Ccnincat.of Consent to sel6insum for Worker's Competr
anion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
7]00 of dhc Isbor Cod.,for the performance of the work IN,which this permit is issued.
My Workers Compeaation Insurance easier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Totts It.need omhccompleted ifdbe Mordit isforonc hundred&Jim(SIFIB -
nr leis.)
1 sentry Nal in the perfi)manec of the work for which this permit is issued,I shall not
emplsyany person inany rn.3 s�ambec me atdl Ano the Workers'Compensation
Laws of California.Date�fa ��-
Applica i y /� 1
NOTICE TO APPLICANT: fter making 0190croficart of tion,you should
become subject m the Worker's Compensation provisions of Ne Labor Code,you mot
.J Z fuMwith comply with such provisims or But Nord h.11 W deemed mooted.
Z'OCONSTRUCTION LENDING AGENCY
'rte Ihereby affirm Nat them is a consmarnn lending agency for dtc Performance or
E
7 dm work for which this pcmd,is issued(Sts.3097.Co.C.)
lender's Name _
�,z Under's Addrem
U Q I certify that I have mad this application and slate that the above information is '
HcortecL I agree to comply wit all city and county ominances and sate laws relating to
�U building construction.and hereby authorim repmmnmtiws of this city to enter upon the .
a above-mentioned properly for insp etion purposes.
(We)agree no save,indemnify and keep harmless the City of Cupertino against
wFa N liabilities,judgomms,coca and expcnsm which may in any way mpmc against said City
U Z in eonsequcnce of the grami of this permit.
^ APPLICANT UNDERST AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO
Re-roofs
Signature OfMphI/ nmam Date
ARGOLIS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum building Occupant tore or handle hvardous material
as dcfmcd by the Cupertino Munici al Code.Chapter 9.11,and On HcaIN and Safely
,116crad..section zssu(an
lion All roofs shall be inspected prior to any roofing material being installed.
❑ No
Will the applicant or future building occupant use equipment ordcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air conmminanls cfncd by the Bay Area Air Quality Management all new materials for inspection.
D'suicQ
❑Yes Nu
1 have toad the hat,LI'm materials requirements mukr Chapter 695 of dbe Calirier.
m.Hcaltb&SafetyCode,Sections 25505.2553]and 25574.1 undreand Nat iflhe Wilding
dos ntRy
hasta=n LNatitrmymspomibilidymnotifytbeoccupmlofde
mgnim i bemmpdormiaammnr.cpnireak .a D Signa[ureofApplicant Date
ownssuNorieed age. ,te All roof coverings to be Class "B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
�j• All the work authorized by this permit
= A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. — All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
- G�iL Get D Co
C r :&6�7C G-1
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/ Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (re erse side). S_
/ "7
Property Owners Signature: Date:
Job Address: 9�i�/ �� Permit# 0 S a�0�
Any changes to the inf rmation Provided on this form 1hall be submitted to the City of Cuyertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
C 1 I p E kT I N O Phone: (408)777-3228
Dear Property Owner.
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors,then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensation*
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S. Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yon,
Building Department,
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO
,���� FUR11iACE/AC os
1UPEiWRTINO PERMIT APPLICATION FORM
APN # /-7O
Building Address: L? So/f
Owner's Name: YT CH �( A I ,AA IBJ Phone#:
)1 Ilf)"/u WAN 2
Contractor: Phone: License#:
1
Contact: Phone: Cupertino Business License#:
Building Permit Info: /
Bldg ❑ Elect Plumb L1Y Mech
Job Description:-7-; sQ/ {�./ w . /�atQr l-nQ air cm Jt�_
Residential Commercial F1 �/J/
For Rei ntial Installations:
ttic Is` floor ❑ 2nd floor❑
dhere to min set back requirement❑
or Commercial Installations:
Replacement same weight E] Additional weight (structural talcs) El
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: � /UVD Type of onstruction: Occupancy group:
O es
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
i
Qty.y. f
A f e Fee ID Fee Descri tion Fee Grou
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 c8n MECHANICAL
tl BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee o BUILDING
BUSLIC Business License BUILDING