05110047 ,CITY OF CUPERTINO :~
BUILDING DIVISION PERMIT tCQN ,"CTT 'ANI''URMATF( N -
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BUILDING ADDRESS: PERMIT N0,0 5110 0 4 7
,10605 JOHANSEN DR
OWNER'S NAME: PERMIT ISSUE DATE
ALAN YUEN 11/09/2005
NE. SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG P.IECI' PLUMB MECH
0
lop LICENSED CONTRACTORS DECLARATION - IObDe3Cr1 Description
1 hereby&farm that I am noticed under provision of Chapter 9(Commencing p
£ who Section 7")of Division 7 of the Business am!Profcsswn Code,and my licensee b� inn full force mid effenREPLACE SEWER LINE & INSTALL C/O
jj: Llccnmclm I3a0q J 71 M90 CONTRACTOR: THE ROOTER SERVICE
p n �Comrscw
.TTARCHIECT'S DECLARATIONe fV.L L
Date Itl
I m densatid my plan Nall he used as public mCoNa
a cad Licensed Professional
by3 OWNER-BUILDER DECLARATION
I hereby alum thin I am exempt from the Comacm's License Law for the
p o fallowing reason.(Section 7031.5,Business ad Pmfeszium Cale:Any city m county
$ which requires a permit to cmmmet,alley.Captain.demolish,a repur any structure
prior In its Wuame,also requires the applicant forsuch permit to life signed summent
€o that be islicenursuan
d Pursuant In 0.pwvisimaaf the constitute.Lice.Law(chapter 9 Sq.Ft. Floor Area Valuat !3800
$ (commencing with Section 7000)of Dintion 3 oftho Buunwand Profession Cook)or
din he ta exempt Ihem(rom and the bub for the alleged eumpdon.My violatian of
Seam 7031.5.airy red oat s(a permit subjects the applicant w a civil pemlty of 3 ApN N�>�I�ei ,/i�� OceupancY'Iype
not mote than A.Canthalicant for
a per 7537 7 ��0
❑1,as owmr of the Property,or my employee with walla u doh wk compensation,
will do the work,and the structure is ml kueded or offered for sale(Sm.'1M4.Bull=
and e n who
obu Cede The Cooucion.aleent!nd
who Law doe set apply f rt owner a _ ` qui �CL10Ds
property who aiwo or improv thereon.and who doe wen woh himxelf Cr Ouomgn his
own bamem,yees provided that Rich improwmana me ran kleededmaffereQ for ale B, ����
beweveethebdl0lagorimprowmeng nit Nthdnutyear a Completion,the aamf {i
builder wig haw,IM burdan of proving vat he did ml build e W ptaw for purpow of
con" �
❑1,u Cater Of the property am excluuvrJy contracting wish liceaaa canuamon w
Conwtn we pmjea(See 7044.Business and Prafaalmu Code)The Commences LL
whore taw coca not syph je ts owns of propenyrho ed four ion ince therein,and
who conwcufarsuchply in
Wthsmf props D)Iho buil puswmwthe Cmun,and
LicenseLaw.
Olson" under Sea ,Od:PCfm this mason
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby alEm under peaty of perjury one of the following dUCWaflon:
1 haft and will maintain a Cmthfhcam of Consent on YII-kwm for Wadmla Cmlprn
sadon,as provided for by Sedan 3700 W the labor Cade,for the perlormmee of the
work fur which ibis pump Is Wined.
❑1 have and will maintain Workers Compensation Insurance,u M4vimd by Scam
3700 of me Labor Code.for Ne performance,of the work for whish this permit is Issued.
My Worker,Compensation hwruce arum and Policy number am: '
Cartier. h r Policy No.:
CEICI7Fl LTTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seaim heed mtbecomplemd If Ile permit taforme hundred dollar($100)
or leu)
1 certify Out in the performance of the work for which this permit Is issued,I Nell not
employ say person in my mannerso as in become subject w de Workers'Compmssden
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after maims this OeniOcao of Exemption,you should
become subject in the Woroces Compensation provision of the Labor code,you most
.,O forthwith comply with Rich provision in this permit Nall be sComa mwkcd.
ti CONSTRUCTION LENDING AGENCY
I.r (hereby aRrm that she.is a comittatin lending agency for the perfmnanm of
G' > thm work for which this permit Is Wined(See.3077.Civ.C.)
W 0 Landers Nm
] Undoes Address
U O 1 coNTy dial I saw read Ws application and sum dead the above thfoneaden is
LL^ Conon.l agree to Comply with all city and eamq oNinna and mu laws model in
C rU^ building Construction,and hereby wmarize mpmenutiw of this city motion upon tie
117 ahold-mmtimcd progeny fon inspection purposes
(We)agree to eve,indemnify and keep hadmkas the City of Cupertino agent
y Iiabilitie.jageacnu.cowsndexpeua whicnmsylnanynyanmcagalneaid City
Uz inconagmnce Cf Lhc Smting Cfthbpcmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ( /
SOUS REGULATIONS, j�Na
Re-roofs o/1
SignTADain
AMATERIALS
DISCLOSURE Type of Roof
WIO the applicant m fuuw Wilding occupant adore or handle hazardous maks
as deRred by the Cupertino Municipal Code.Chapter 9,11,and the Health and Salmy
ale.Section 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ye 40
WIII the applicant i fulort building by ft Bay A equipment.Air Qu m dMana Management
If a roof is installed without first obtaining an inspection,I agree to remove
-...� which
mtrict? w air conuminanu defined by the Bay Area Air Quality Mangemem all new materials for inspection.
District?
❑tin u
I haw read the husedous materials mquimmem,underChapter 6.95 of the Califon
Me Health A,Safely ode,Sections 155115.15533 and 25534.1 maintained the irlm building
din mt eu.ntiy have a u n m.that it b my msponihility,in ncdfy the occupant of the
requirements which maxi W mel prior In issuance of a Comficau of Occupancy. ' Signature of Applicant Date
Owner or antra a end am All roof coverings to be Class"B"or better
x Community Development
J 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEf�TINO •
'Building Department
JOB ADDRESS: PERMIT#
6)cP'//06 4�
OWNER'S NAME: 1A.1PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: _ �r ���•,-> �
Signaturea� D to
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
i
Owner Contractor Signature ate
ap%�� CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
•CUPEkTINO PERMIT APPLICATION FORM
APN # \ �f 37 S�� Date:
5 o i
Building Address:
Owner's Name: Phone#:
V g
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License#:
Buil ing Permit Info: /
BldgEl Elect El Plumb lld
Job Description: '7&'1+ of I;NG rcpt ac;�7
R sidential Commercial ❑
Cost of Project:
oldd"
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFE-E Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures . PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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