06010016 4 CITY OF CUPERTINO i '0"+ f �ba •'
BUILDING DIVISION PERMIT' CO1�rRACTUR�IIVFURMA"fl�QN ,
BUILDING ADDRESS: BAY AREA REPIPES PERMITNO.0 6 0 10 0 16
OWNER'S NAME: PERMIT ISSUE DATE
salkSOANNE CHANG 1861 ORANGE GROVE DR 01/04/2006
NE: SANITARY NO. CONTROL NO.
(406) 371-5763
ARCHITECTIENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Y00
LICENSED CONTRdunderSDECLARATION JobDescri tion
if�+ 1 hereby J).f that I am licensed under provisions of Chapter 9(Commencing p
With Section 7g1U)o(Dividon 3 of Ne But.arW Profcuinm Code.and my license is
n inlull forceanaercet Sri REPIPE/REPLACE WATER HEATER
z
9 Licanse Clan
Deis Gam
ARCHITECTDECLS DELLA A O /jp�'
5 unMrwnd my plana Nall be used u public nand, I{� B
'G� Licensed Pmfnsionat o ��
g OWNER-BUILDER DECLARATION
i a I 1 hereby.(firm that 11. .Bumpy from the Canon Cod License Law for the JA `T�IJ�\/6\f
aoO Which
mason.(Section7031.5.Business and Profession Co dc;Any city or county A' <
.�$ which Coquina a eormh re cnmouc4 alar,improve,h Pormil t ore a sig any co meet `tf _ $5000
�y pnarmslissuance,elaumg theprevisionNi offor SucConnector's
License LAWned
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that he is licensed pur,uemmUse prevision of the ConoecmrilJoome law(Chepur9 Sq.F[.Floor Area - C(/46 Valuation
that Zia exempt
Section and the alis for
sh tie B ed cxm d w.Any
vi Cnde)or OVA
,
Net io la campy therefrom and the bah lar the shoed exempnt to Any violation of A h not mom
70315 five
my applicant fora permit subjects the applicant u•civil penalty of r ` '�ar/ Occupancy Try
trot more dun Bw hundred dalWs(gd00). � p y •lpe
❑1,as owner of the property,or my employees with wages As Neo oak eompsmation,
will do the wod4 and Iles someone is not Intended Or Offered rW Asia(SIX.7044.Business,
and Pmfesdona Tim e Cmuna 's LiamLaw don not apply to an Owner of Required Inspections
Property who builds ser impruws Moemon,and who does ouch wart himaelf or through his
awnemployen,provided thatsuch improvemenu are natinumded"offered Resale.if,
however,The building or Improvement is mid within one Year of completion,the Owner.
builder will hew the burden of proving that he did not build or Improve for purpose of
sale.).
❑I,as Owner of the property.am"elusively contracting with licensed contraction;to
Consumer she pmjem(See.7044,Business and Profession Code:)7125 COnso clor',U.
conic law don not apply to an owner of propeny.who build,or improves thereon,and
who contracts for Much projeeu with aconoaclor(s)licensed pursuant lo de COnoseuse.
Lkense Law.
❑Iamecemptunder See .B&PCfmthbmuon
Owns Dau
WORKERS COMPENSAT70N DECLARATION
1 hereby aRrm under porosity of perjury one of tie following declaration:
1 haw and will maintain a Cenifieam of Consent to self-asure for Worker's Compen.
sation,u provided for by Section 3700 0(the labor Code,(or the performerc of the
work for which this permit u iemN.
❑1 ban and will maintain Workeh Compensation Insurance,u required by Section
3700 of the Labor Code,far the performance of the wort for which this Permit is Wised.
My WmkC sgjan inaamoee Carrier and Polity number am: I,. I
Canter. ��fyM�.. �wV/I Policy No.:'X2.go L ZY?7l
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need trotbucampleted time permit Is forone hundred dollar,(SIM)
or[Co..)
I Certify that in the performance of the work for which this permit is Issued,l shall not
employ any person in any mannerw as An become subject to the Warkera'Compensation
Laws of Califamla.Dau
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation pmvinons of the labor Code,you muse
.JO faMwith comply with such atwistam or that Permit wait he doomed revoked.
Z t"' CONSTRUCTION LENDING AGENCY
[y.y. I hereby AM=Most chert iso construction lending agency for de Performance of
C ti the work for which this permit Is issued(Sec.3037.Civ,C.)
L okes Name
CL 7 z Lender's Aadmsa
U Q 1 certify dal I have mad this application and Aum that the above Information Is
U.(~ comt l agree to comply with all city and county ordinances and ante laws relating in
O V building construction.and hereby authorne reproxnadws of this city to enter upon the
�r Cil above-mentionW pmpeny for inspection PurpoaeL
F gy (We)agree to save,indemnify and keep hamlesa the City of Cupenino against
,.y rA Iiabilitiea.judgmenu,Cosa en des a which may in any way accrue ageirut said City
U 7 in Coveq=CC of Um SMdng of A permlL
w7 APPLICANT NDERSTA ND WILL COMPLYWI LL NON-POINT Issued by: Date - G! -O
SOURCE L 0
{' Jp�J.&'v
Re-roofs i
SignturcAppliunVContncmr Dau vv"�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliam or future building oaupanumre or handle hicummus material
sa defined by the Cupertino Municipal C de,Chapter 9.11.and the Health and Safely
11,
de.Section 2S531(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya Na
Will the applicant or future building ooapnt us;cyuipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazatdnuA air canuminanu cflncd by tise Bay Amo Air Quality Manlgemem all new materials for inspection.
❑Yes NuI how read the hmardnm n aurlat'rcuiremenu under Chapter 6.95 of t e Califor.
Health a SfcryCode,=u25505.15573wu12533/.I undemend dor ode building
cs not Dgyly, u that It is my napo a llh nULy tie oaWa.t of the
each. m .arLl�laaatmeo(a 'r raarapancy.nSignature of Applicant Date
�T K y All roof coverings to be Class"B"or better
Ow r uthorixedi Dau
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
6 ovl IucO r 1 0661160 ( 6/
OWNER'S NAME: o n.14 eA4N-7 ONE # 973 — 7'5-/ S—
GENERAL
5-/ S-"GENERAL CONTRACTOR FAX #
I am not using any subcontractors: 0 5� to
tgnature Date
Please check applicable subcontractors 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
J4
caner on actor Signature Date
r .- - CITY OF CUPERTINO
CU �C,
-Y0 O PERMIT APPLICATION FORM
orN # q ' D Date:
wilding Address: e Mailing Address (if different from building address):
Owner's Name: fig Phone#:
97 9srisr
Contractor: License#: 3
PrrzL,
n C -es m
C tact: Phone: Cupertino Business License#:
�akh Stein o n Fax: 3 773
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 2'/ Mech ❑
Job Description: ojpt en-'.'x,e- 1-6+- q nj Col wnisr I ants
Residential ,\ f Commercial ❑
Sq.Ft. Floor Area:
/ 3.0 L)-0 5
Cost of Pro' ct: Occupancy G>*
So�o,�o r[
Type of Construction: " Please check this box if the project is a
t�0*
second-story addition: ❑
AlkrojectSize: Standard t. Laze ❑ Major ❑
Quant Fee ID Fee Description Fee Grow
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> 1.75MBtu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTA)MQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600Y > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
,t CUPEfZTINO PERMIT APPLICATION FORM
uanti 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
BOVERTIIv1E Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 BUH DING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstaH/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
13REMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY .. Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREAMH MOOD Installation of Hood MECHANICAL
BRENDMC 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 Appliance ELECTRICAL
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OTYCITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sigas, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems 11IECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspwtion BUILDING
BSSWIM 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
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMTTFEE Alech Permit Issuance MECHANICAL
PPERMTTFEE
Plambing Permit Issue PLUMBING
PPLBG PlumbingFees foot PLUMBING
PLLONGRNGC PlanningLR Comme/Multi-Faro PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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