04080251 I .
CITY OF CUPERTINO •r � ra " a
BUILDING DIVISION PERMIT � GONTRAGTOR INFORMATION ?:
BUILDING ADDRESS: PERMIT NO.
TSAI-HUNG LO 04080251
M PER In ISBUEDATE
NE:
SANITARY OL NO.
RCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
yoo
LICENSED CONTRACTOR'S DECLARATION JobDescrip D
d�i❑ I hereby off.dust 1 am licensed under provisions of Chapter 9(commencing
aRj with Section 7")nf Division 3 ofthc Businessand Professions Code,and my license is
. y in full force and effect.
License Class Lie.N NEW BRACKER SEP
-a Date Outstation, / 1004
ARCHITECTS DECLARATION
WV I understand my plans shall W used as public records ff t1 fI RRka f1 �1
05 Licensed Professional O 11 II�'I ��IN` II�
OWNER-BUILDER
ar I s.cU m,,fir DECLARATION ON V 11L�] IUI\\vf
.� I he¢by affirm Nat I am exempt from Bee Cmndacmrs Littnu law for W
0 0 following reason.(Section 7031.5,Business and Pmfestiom Code:Any city or county
m which requires a permit on curnmet alcor,improve,demolish,or repair any structure
Fly prior In is issuance.also mquims the applicant(orsueh permit to file a signed statement
fs that he is licensed pursuant to the provildcmofthe Comncmr'sLicense Law(Chapter 9 Sq.Ft. Floor Area Valuati
ef- (commencing with Section 7")of Division 3 of the Business end Professions Codc)or
i $ Nat M is esempt Ber.from and Bee books for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicator to a civil penally of er Occupancy Type
not more than five hundted dollen(5500). 3 � . 00
0 1.towner of rhe properdy,or my employee with wage oo Weir sole compensation,
will do the work and the swctum is not intended oroffmod forsale(Sec.7W,Businw
and Professions Code:The Conuactors Liana Law doe not apply to as owner of Required Inspections
property who builds or improves demon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered forsale.if.
however,the building or improvement is sold within one year of cconnedon,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors m
construct the porn.,(Sec.Was,Business and Professions Cade:)The Coo errors s Li.
me Law does not apply to an owner of property who Wilds or improve thereon,and
who contracts for such projects with a contrasonr(s)licensed pursuant to the Communes
License law.
0 1 am exempt under Sec. B&P r this reason c
O e _ De - 7e-
WORKEWS' MPENSAT7 NDECLAR
1 hereby affirm under Wholly of Perjury ane of the folio laratiom:
',I have and will maintain a Certificate ofConsent to self-inseam for Worker's Compen.
—don.oo provided for by Section 3700 of Be labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance.az equ led by Section
3700 of We labor Code,for the NdO.anee of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Polity No.:
CERTIFICATE OF E%EMP ION FROM WORKERS'
COMPENSATION INSURANCE -
(Thisseclion ran d maNconpleed truce Permit is for one hundred dollars,(51fq)
or less.)
1 certify Nm in c performance of We work for which this pc it b issued.I shall not
employ any perse ymanmr mhaomgsuTbjecton WCWmm Cgmpemauon
I of Califo ¢ s� ! — ,
A cam
I TO,APPCie :If,of making this C cmc of Exemption,you should
be o subject 0 the Worker's Compensation previsions of the Ichor Cndc,you must
2 fo with comply with aue6 provisions or this pormil shall W deemed revoked.
Z O^ CONMUCfION LENDING AGENCY
1 hcony offrm that Bens is a construction lending agency for the Performance of
Ca 7 the work fur which this permit is issued(Sec.3W7,Co,.C.)
It]a Lender's Name
=Z I.cntlers Addnss
U O 1 muni!,den 1 have read this application and sir¢that the a Wve information is
LL P correct I agree m comply with all tidy and county oNinanxs and state laws elating on
0 U building construction,and hereby authome representatives of this city to enter upon to
C auovcnumdrned p.,try for inspection purposes.
(We)agree to ave,indemnify and keep hannien the City of Cupertino against
F'N Hebrides,pdgm.ns.cons and experucs which may in any way accrue against said City
U in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL N -POINT Issued by: Date
SOURCE REGULATIONS. _ _ JAI
CJ e-roofs
Si ns, rcof ApplicanUConuacmr
HAZARDOUS MATERIALS DISCLOSURE J Type of Roof
Will the.Rdicam or(urease building occupant smm or handle haallous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heabb and Safety
Cod.,Se❑elm.2553](.)? No All roofs shall be inspected prior to any roofing material being installed.
Will Bee a licayes m sur s'lutildin cora and use. t sur devices which If a roof is installed without first obtaining an inspection,I agree to remove
pP 6 P 4uipmcn
,it
havar11 -air conuminants ai deft!by the Bay Arta Air Quality M....mocm all new materials for inspection.
evict?
by.,
IhavereaddoloonNo sm 'alsmquimm.nuunder Chaper6.95mfthc Califor- .
nia HeaU&Safety Code,Secuom25%5,25533and2553a.lunWmmdWniftie Wilding
does nod Currently have a tenant that it is my responsibility to nobly do occupant tf We
requimmen whit ctpriurw' seance f. -ri sem! eup Signature of Applicant Date
ownorauhmiipadagene ere 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
A. — All the work authorized by this permit
B. 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
fo:—.e.'�
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 employes (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/City 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(reverse side).
Property Owner's Signature: Date: " —`D
Job Address: 2 �c�L4-.41��_L/IL5 � Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Deyartment.
City of Cupertino Building Department
CITY OF I D30D Torre Avenue
C'w
I P E kT'N O Phone: (408)777-322F
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.
't 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 yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
- CITY OF CUPERTINO '
CITY OF PERMIT APPLICATION FORM � d 8„ Z S /
CUPEkTINO
APN # z 2 D�- Date:
Building Address: Mailing Address (if different from building address):
14 2 Oo ri
Owner's ame: � Phone d J -
Contractor: I ILicense7 45
#:
Z�
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descriptio�}� cc J �G2 G
Residential ❑ \ _ Commercial ❑
Sq.Ft. Floor Area: S/Sq.Ft.:
Cost of Project: '�'� Occupancy Group:
(Prcjeect
of Construction: Please check this box if the project is a
second-storyaddition: ❑
Size: Standard ❑ Large ❑ Ma'or ❑
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 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/OfFComm/Quasi 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 .,
ambl-
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEI�TINO
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 rinklerBackflo PLUMBING
BPSTORM Storni/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 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfrn MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREVE RAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
Ly BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
k= CITY OF CUPERTINO
CUPERTO PERMIT APPLICATION FORM
QuantityFee 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
ZADDCHG Address Chane BUILDING
f
3 of 3