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05010101 CITY OF CUPER'fINOr et^ . 0 •� A�- -' s'�= ' BUILDING DIVISION PERMIT qq�CONTRACTOR;INFORMATIQN 7�aL^"e.�is, BUILDINGADDRESS: YQM CONSTRUCTION PERMff No05010101 NERs NAME: PERMIT LS11E DATE BEN WANG 5156 PROCOR AVE, ONE: SANITARY NO. CONTROL NO. (510) 661-6775 ARCHITECT/ENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB MECH I� o 0 0 yOZ LICENSED CONTRACTOR'S DECLARATION m° I hemby grim that I am licensed under provisions of Chapter 9(commencing Job Description �2E with Section TOfyd)of Division 3 oflhe Business arW Professions Code,and my license is „« in on Claanderrect. C 27a�� REVISION--IN HOUSE USE ONLY S u. Liccnm Clea lx. ZFp Dau ^TTA c,,r r-g DECLARATION NO NEW PERMIT ISSUED/ ORIG. #04040193 Y U 1 understand my plans shall he uutl a public records u Licensed Professional =OS OWNER-BUILDER DECLARATION I 1 hereby affirm that I am exempt from the Connector's License Law for the 00 following reason.(Section 7031.5.Business and Pronasion,Code:Any city or county y$V which osproas a permit ro envtnct,alua impmvc,demolish,or repair any awmun prior to its issunnec.also requires the applicant for such permit to life a signed statement P ° that beislicensed puwan00the ProvisiovMtheContneauriUcenuLaw(Chapter 9 Sq.Ft. Floor Area Valuatio,$115 ¢� (rommeneing with Section 7")of Division 3 of de Business and Professions Code)or to y $ Nat M u exempt thertfuse and the basis for the alleged exemption.Any violation of Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not mom Nan rive hundred dollars(ISM). P Y YP ❑I,as Owner of the property,Or my employer with wages a their sole compensation. 37527006 . 00 will do the wurk,and the structure is not intended or offend int sale(Son.7 a,Dusi. and Professions Code:The Contractor's License sew does not apply N in owner of Required Inspections property who builds or improves Hereon,and who does such work tonsillar through his Own employee,provided that such improvements are not intended proffered for ale.If. however,the building or improvement is sold within ane year of completion,Ne owan,. builder will have du Wrden of proving that he did not Wild or improve for purpose or /a sats.). ❑1,a owner of the property am exclusively common,with licensed contractors N consumer the project(Sec.704,1.Business and Professions Code:)The Cummins's Li. �. cove Law docs not apply to an owner of property who builds er improves Noreen,and, �y who contacts for such projects with a eontasomr(s)licensed pursuant a Ne ConuacraM1 License Law. ❑loin exempt under Sea .B d:PCfar this reuon nor Dau WORKER'S COMPENSATION DECLARATION 1 hereby aRmt under Penalty of perjury one of the following declarations: I have and will maintain a Coniricam of Consent xlf--insure for Worker's Compere moon,a providW for by Section 3]00 of the Labor Civic,for the peRonmanco of Nc work for which this permit is issued. ❑1 have and will maintain Worturi Compensation Imurana,in squired by Section 3]00 of Ne Labor Codd,for the pcffonnance of the work for which this Permit is issued. My Workces Compensation Insurance carrier and Polity number are Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (ITu section need not bocanplcud if the Permit is for one hundred dollars(SIM) Or lcssJ 1 certify out in the peamorr vic or Ne work for which this permit is issued,1 shall not employ any Person in any manner m as N become mbjecO0 the Workers''Cont,smation Laws of California.Dau Applicant NOTICE TO APPLICANT:If,after making this Ceniricau of Exemption.you should become subject W He Worker's Compensation provisions of the Labor Code,you mon .,O forthwith comply with each provinces or this Permit shall he deemed revoked. Z " CONSTRUCTION LENDING AGENCY [—�� Ihereby affirm door Nee is a commusedon lendingagency for the performance of CLHe work for which this permit u issued(Sce.3097,Civ.C.) 427 Q lender's Name Lender's Address az U 0 1 certify that 1 have read this application and state that lie above infomution is 4y Pconnect.I agreeand to comply with all city county ordinances and state laws relating tp U building conswcuon,and hereby authmin repmnnutiwca Of this city to enter upon the >"W abovcmenamod property,for inspection purposes. F G, (We)agree to ave,indemnify and trop humlea du City of Cupenino against h liabilities,judgmcnu,eoss d,s,.which may in any way accrue against aid City a U Z inconsequence of the Seaming Of Nis Permit. s APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature ofOf Appb� Dau HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding Occupant nom or handle hazardous material as defined by the Cupertino Municipal Codd.LTapter 9.12,and He Health and Safety otic,Section 23532(4)7 Yea All roofs shall be inspected prior to any roofing material being installed. 'IGrFsu Will the applicant or future Wilding occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Diu kr? ❑Yes 1"Me __1- I Ihavemad the hvarduusmaurialsneyuinemenu underCTaPurl6.95 Of tagifhe Califon- Til rias hall a Sectiorshat it 4 myhand1f5)a.I to noun t eOccup Wilding /' Z dens net curtcndy he.c a tenant that it u my espovihility m notify Nc oecupant of the myuimmens whIcYrouu be met� prior w issuanceora Cori f /���S Signature of Applicant__--�---- Date y J Owner or authnn,cd a0nu S'— Dat — -All roof coverings to be Class "B"or better &�(��tmvs WITY OF CUPERTINOS CUP TYOF O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 Inspection BUILDING BSVIWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUS IC 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 3 of 3 CITY OF CUPERTIN(O CITY OF PERMIT APPLICATION FORM ` CUPERTINO 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 Atmos heric 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 BUILDING 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 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 cfm 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> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL v 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 CIS, CITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM S i CUPEkTINO APN # 3 7-r Zs—, e--u. Date: I o L Building Address: Mailing Address (if different from building address): I 61S Owner' Name: Phone #: %C) lAs CI.Yq� Contractor: License #: J M ? '1 Contact:\\ Phone: 379' Z6S 1 Cupertino Business License#: J •erz N-�\ Fax: 3-7 9 XS7 C7 Building Permit Info: Bldg Elect I1 Plumb Mech 9j Job Description: Residential ' P Roti rv'kr f"'A Commercial ❑ Sq.Ft. Floor Area: a00 S/Sq.Ft.: Cost of Project: Occupancy Group r Im Typ of Construction: Please check this f t oject is a M2 second-stor addition: Lj Pr 'ect Size: StAHzd Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/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 Elee 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING ' BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF CUPERTINO BUILDING DIVISION PER �X-QNTRACTIl� OR FO ION. BUILDING ADDRESS: JM CONSTRUCTION PERMITNO.04080145 ' ''WNER'S NAME: PERMITISSUEDATE jFbNE: SANITARY iftOL 10. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 Loo LICENSED CONTRACTOR'S DECLARATION JobDescri tion 1 hereby affirm that I am licensed and r provisions of Chapter 9(commencing p iT with Section 7")uf Division 3mf the Bus and Professima Code,and my license is T in full fo deffect � i Lmcrsc ill Lm.k 73 6056 FIRE DAMAGE REPAIR Contractor ARCHITECTS f]Vi. GG��RATION T— �i w I understand my plans shall he used aapuMi. U records 3a o t; Licensed Professional r. S OWNER-BUILDER DECLARATION S I hereby alive tial 1 am exempt from Ne Contractors License Law for the O4 following reason.(Section 7031.5,Business and Professions Code:Any city or county x m which requires a permit to consumer,alma,improve,demolish,or repair any structure Fiy prior or its issuance.also reyviru the applicant for such permit to fileasigned statement - < that he is licensed pursuant(it Hoe provisions of the Corturector's License Law(Chapter 9 Sq. Ft.Floor Area Valu hon (Commencing with Section 7W07 of Division 3 or the Business and Professions Code)or i Nat he Is exempt theafmm and the basis for the alleged exemption.Any violation of 'ection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 'p1$yygT,�erpp Occupancy Type net tome than five hundred dollars(55001. 0 I,as owner of the property,or my cmploycee with wages az their sole compensation, will do the work.end Ne structure is not intended oroffered formic(Sec.71k4,Business and Prelessimu Code:The Contractor's Literate taw does not apply a an Owner of Required Inspections ownenywho yees.pdamimpmves thcmonand who are work oroff redOr lhmugh his _ l neer.be or ded prowarm such imps sold within net intended for sale.It. builder..Ne hve the or improvement is sold within one year of completion,meowner. of builder will have the burden of roving that he did not build or improax for puryox of sale.). ❑h as owner of the property,am exclusively contracting with licensed contractors to C ' construct the project(See.7014.Business and Prof sdiom CWc:)The Contractor's U. / cense law don not apply to an owner of property who builds of improves thereon,and who coronets for such projects wit a contractor(s)licensed pursuant o the Contractors License Law. 0 J lexempt under Sec. .B&PC for this reason Owner Data O� WORKER'S COMPENSATION DECLARATION 1 hereby alarm under penalty of perjury ooe or the allowing declarations: V ❑I hats and will maintain 2Cc tiftcme of Contend to self-insum for Worker's Compere sarion,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 Workers Compensation Insurance,rs required by Section 37W of the labor Codc.for the performance of the work for which this permit is issued My Workers Compensation Insurance carrier and Policy number art: attic:Sj4lE �V N� PolityNo.:_ 050 G� CERTIFICATE OF EXEMPItON FROM V ORKERS' COMPENSATION INSU (This section and not M completed if the fermth is for one hundred dollars IS NR or It..) I certify that in the performance of the work for which this permit is issued,l shall nut employ any person in any manecrsn as at become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should beeume subject 10 the Worker's Compensation provisions of the Labor Code,you must .,,'Z fnMwith comply with such provisions or this permit shall be deemed evoked. Z O CONSTRUCTION LENDING AGENCY (•"� Ithereby alum OutOur.iso exr¢wclinn lending agency for pelfurmonca of athe work for which this permit is Issued(See.3097,Civ.C.) ts] leachers Name Z) z Lenders Address U C) I certify that 1 have read this application and state that th<ahow Information is e. F correct.1 agree to comply wit all city and county ordinances and sue laws relating to 0 building construction.and hereby aulhorim repreacnounna,of this city to enter Cram the tc ahove-memioned properly for inspection Ponoses. (We)agree m save,indemnify and keep harmless the City of Cupcnino against C. liabilities judgments.costs and expenses which may in any way see=against said City U Z in consequence of the gMating of this permit. ^ APPLICANT� UNPERSTANX AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE U TIONS. Re-roofs Si,WImeofgppi� ci ri� Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof ' Will the applicam or future building mcupam atom or handle hazardous material ecrncd by the Cupertino Municipal Coee.Chapter 9.12,and me Hcaith and Safety de,SCCCY a 25532N)? Nu All roofs shall be inspected prior to any roofing material being installed. Will If a roof is installed without first obtaining an inspection,I agree to remove the applicant or future building acupant vu equip enl or devices which c emit harardous air conmmianandcfmcd by the Bay Arca AirmQuality Management all new materials for inspection. District? ❑Yes No I have mad the hanolous materials requirements under Chapter 6.95 of the Califon r al Safety Coda,Sections 25505,25533 and 25534,1 understand thxl ifthe building 6 0 �nen ave ant.the it is my resp hoOtIity to runty the occupant of the he he nts.vhV ermdpanrwhauarc,cofacemrcateo(Occupancy. Signature of Applicant Date Gweronaemorir agent I I ate All roof coverings to be Class "B" or better ' CITY OF CUPERTINO 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37528033 . 00 DATE ISSUED. . . . . . . : 08/17/2004 RECEIPT # . . . . . . . . . : 26717 REFERENCE ID # . . . : 04080145 SITE ADDRESS . . . . . : 10568 JOHNSON AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : DOUGLAS CHANG ADDRESS . . . . . . . . . . : 10568 JOHNSON AVE CITY/STATE/ZIP . . . . , RECEIVED FROM . . . . : JM CONSTRUCTION CONTRACTOR . . . . . . . : EDENS, JIM LIC # 20955 COMPANY . . . . . . . . . . : JM CONSTRUCTION ADDRESS . . . . . . . . . . 562 DIVISION ST CITY/STATE/ZIP . . . CAMPBELL, CA 95008 TELEPHONE . (408) 379-9852 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW 'BAL ------ ---- ------------- ---------- --- - - -------- ------- --- -- BPERMFEE VALUATION 45, 000 . 00 496 . 80 0 . 00 496 . 80 0 . 00 BPLANCHK PERMIT FEE 496 . 80 662 . 98 0 . 00 662 . 98 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00 BPTRAP NO OF TRAPS 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BENERGY PERMIT FEE 496 . 80 238 .46 0 . 00 238 . 46 0 . 00 BREMINHOOD NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BREMPOWER POWER UNITS 1 . 00 47 . 96 0 . 00 47 . 96 0 . 00 BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00 BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00 BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 BSEISMICRE VALUATION 45, 000 . 00 4 . 50 0 . 00 4 . 50 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 --- ------- ---- --- --- -------- ------ TOTAL PERMIT 1683 . 29 0 . 00 1683 . 29 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER -- --------- ----- - ------------ ----- ------- CHECK 1683 . 29 27550 TOL RECEIPT 1683 . 29 } — � F , o " lawful tp m lii: nyrcha _- - ,on same WMOUt wnntte "` "the b HOd,r Dapt City_ t The stamping of this pls .i :,;3HALQ'WT beheld to - �.p app4 jllof;tho *lDtlW r' if an, Chy Ortlinnnse q T } 1111 I i .� -77- le kk rs r 4� t _ AUG 171004 a� I �CITY OF CUPERTI j .:goas� ninir ®EPA t ! 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