04090263 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COIT,TRACTORNF�®RMATION
BUILDINOADDRES: CHUNG YIN WONG PERMIT No 04090263
OWNER'S NAME: PERMIT ISSUE DATE
HE SANITARY NO. NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo0
LICENSED under
- ,tl® n (.# ��®
=�C 1 Mmby off IC Net I am CONTRACTORS
TOR provisions DECLARATION
9(commencing - _ Job DeScrl stpy7{�[�ys,P[Dlt9///��\�
i wish section Division 3 ofthc Business and Proressiuns Code,and my lite=is
,,a iamu am aneerrect. TEMP POWER POLE
i P G Dan Class
Contractor
ARCHITECTS DECLARATION SEP,30 2004
1 understand my plms shell W used as public records
Dau
ts Licensed professional D p I ®�
`ct3 OWNER-BUILDER DECLARATION pD�/u■
i 0 I hereby.(Sero Nat 11. exempt s an Ne Canvmmfs License Law for she
00 whichingmason.Permit
to construct,
Business and improve,
deNuu Codon:Any cin or county
K m ff which myuims n pcmit u,conlwcL applicant
improve,do ermit t fi mash any structure
''a�'^ prion.iuiensedprsuantsmltalso o the the
ovisioso for such Contractor's
Licenfile ase
ned Law
��<
that me licensed pursuant so the Provisions of the the Business
nd Professions
(Chaptcr9 Sq. Ft. Floor Area Valuation
that he
(commencing with Section Trial dth Dunsfon r the
alleged
exeapton.Any
Cade)or
y $
that io u dumps thmefrom and she Eur far Ibe alleged exemption.Any violation of ',w1.t-N.aw.4.
7031.5 by an,
reddapplicant s($!0permit mbjew de epplicanno.civil Penalty of 36"Wk,5C4Ya1VO 0 Occupancy Type
not more Nan Bae hundred dollen(5300).
0 I,uowmrofthepmpmn ormyemployeeswishwagsuthckroleeompewsion,
will do the wank,and she sumctum is not imended oroRered foream(Sec.7004,Business
and Professions Codc:The Conuamors License Law docs not apply to an owner of Required Inspections
property who builds or improves Nercon,and who does such work himself or through his
awn employees,provided our such improvements are not intended motioned forsate.If.
however.the Wilding or improvement is mid within ane you of completion.the owner.
Wilder will have the Wrelm of proving Nat W improve(.1 not Wild or improfar purpose of
sale.),
0 1,as owner of out property,am uclusively contracting with licensed cmvacmrs in
consumer the pmjcct(Sec.7 4 ,Business and Professions Code:)Tho Canlnemr'l Li-
u law data not apply to an owner of property who Wilds or improves emmon,and,
who contacts for such projects wish a co deactor(s)licensed pursuant o the Convector's
License law.
0 l am exempt under Selc. [� .B h P C for this reason
r Od "�11 Mr— Dart —Z TV
WORKER'S WMPENSATION DECLA0.A uN
1 hereby affirm under Penalty of perjury,one of the following decimations:
1 have and will maintain a Cenificam of Consent to self-insum for Workeh Compere
sedan,as provided fm by Section 37W of Ne Labor Code.for the penfmmance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compmemom Insurance,as required by Section
37W ofue Labor Cage,for On peRormsece of the work for which this permit is issued.
My Wormer Compensation Insurance canner and Policy numbor am:
Carier, Policy No.:
CERTIFICATE OF E%EMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This minim need at boeomplmed irthe permit is fmonc hundred dollars($100)
or lux)
1 Molly that in the performance of the work for which this permit u issued.I shall not
employ any person in any manner an as to become subject 0 the Workers'Compensation
Laws of Catboat..Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificas,of Exemption,you should
become subject to On Worker's Compensation previsions of the tabor Code.you must
.,O forthwith comply with such provisions or this permit shall he dictated revoked.
z CONSTRUCTION LENDING AGENCY
I hcmby affirm that there is a construction lending agency for the Performance of
l� the work fur which Nis permit is issued(Sec.3097,Co,C.)
W Q Lemic/s Namc
=z Lender's Address
U C) I certify Nat 1 bane read this application and some that me above information is
g, F-' conect.I agree to comply with all city and county ordinances and sue laws relating m
0U building construction.and hereby auNome,epamnmies of this city to enter open the
} W above-mentioned property for impaction Purposes
0. (We)agree to an,indemnify and keep humblest the Cor of Cupcnino against
N
liabilities,judgments,costs and expenses which may in my way accrue against mid City
U in conugoenec of the gaming of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date a
SOURCER CATIONS.
Re-roofs
mune of Appl ianuC vector Dae 7-0 f
H RDOUSMATERIAISDISROSURE Type of Roof
Will Ne applicant m forum Wilding occupem smmp-handle bvueaus maodal
v as deRncd by Ne CupeNm Municipal Code,Chapter 9.92,and tW Health and Safety
Coes,section 25512(x)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yoe Lola P P Y g $
Will the applicant or future building Occupant use equipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardaus air contaminants as dcfimd by the Bay Arca Air Quality Management all new materials for inspection.
Disuin?
O
yes
Nu
I have read Ne hvarAms materials requirements under Chapter 6.95 of Ne Califor-
nia Health A Sam yCode.Sections 255(15,25533 and25534.1 understood that if the Wilding
data not currently have a tenant,that it is my uaperaihility to notify ete supant of the
requirements which most W met prior mismance ofa CcnB or(kcapanry. . Signature of Applicant Date
t Z 7� All roof coverings to be Class "B"or better
Own' rauNamed eg t Date
_ Community Development
10300 Torre Avenue
l Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
UPEkTINO
Building De artment m, r
JOB ADD SS: PE IT # �1263
OWNER'S N K PH # 4d- 93 o,
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
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
Owner c r Signature Date
CITY OF CUPERTINO
am,
TEMPPOWER
*"EkT iNO PERMIT APPLICATION FORM
APN #3 ! Date: S Z
Building Address'
o g• Y:ve no CA q
Owner's Name: Phone #:
7'm fu CAI 1,44 4�,, 40d� -�30 -98710
Contractor: Phone: 6 License#:
40 k- 306 � 8"
Contact: / Gly Phone: 4�� 30 3�� Cupertino Business License #:
Building Permit Info:
Elect ❑
Job Description:
�"� • POurei✓ .
Residential Commercial ❑
Cost of Project:
p i v.00
Qty. if
A li e Fee ID Fee Description Fee Group
EMP Temporary Power ELECTRICAL
ERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
T ` �r