04040092 CITY OF CUPERTINO ti a Fx :xta mar `r�i fzv d ,
BUILDING DIVISION PERMIT �C,0NTRXGT0,RANE0 MATION-
BUILDING ADDRESS: PAUL POON PERMIT_N
1074 LAVINA CT
0 W NF:R'S NAME: PERMIT ISSUE DATE
PAUL POON 21074 LAVINA CT n4Z15Z2004
ONIi: SANITARY NO. CONTROL NO.
ARCIIIIT'.CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
200 LICENSED CONTRACTOR'S DECLARATION
t C 1 hereby affirm that 1 am Boned under previsions of Chapter 9 anmmencing Job Description
^7h with Section 70gp of Division3.ftne Businmsand Professions Cede,and my license is
in
Class Lic.ro Fall force errea 2 WALL FURNACE/WATER HEATER
L
,j O Data- Contact.,
RL asj ARCHITECTS DECLARATION
U I undersand my plans shall he used as public records
i O Licensed Pr.fessinnal
OWNER-BUILDER DECLARATION
<V 1 botchy affirm that I am exempt from the Contractor's License Law fur the
O o following reason.(Section 7131.5,Business and Pmfexsions Code:Any city of county
uw� which requires a permit to construct,alter,improve,demolish,or repair any smetme $750
prion-its issuance,also ayoires the applicant forsuch permiuo Elcasignedsamocnl
�zp that he is licensed pursuanl 1it the previsions or the Commuter's License Law(Chapter Y Sq. Ft. Floor Area Valuation
xt- (Com mooring with Section 7000)of Division Sof the B usinem and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section7031.5 byanyapplicatforapeouit subjewthe applicantto acivil irraltyof 3a(PRN1ih9er00 Occupancy Type
not more tWnImhundred doimrsS50H. P Y YP
❑1,at owner of the pmperty,or my employees with wages as Ncir sole eompensmion,
will do the work,and the structure is not intended or offered for sale(Sec.71W4,Business
and property
obis Code:The Conductor's Lianas Law aces nut apply to an owner of Required Inspections
paperywhobuildsored that su Noor.,and who does sum work oroffred Ihosle his
own employees uilding or i m r men imprevedW kt are not immntictl or offered rte sale.If.
however the building or improvement is ala within one year or completion,the owner.
builder will oars the Horden of proving that he did not Wild or improve for purpose or
sale.). ,(�
❑1,as owner of me property,am exChlo ely contracting with Licensed contractors to Vi
consumer the project(Sect PIA,Business and rtowho Wilds
ds or improves The ves th mon. fid
cense law docs sol apply m an owner or property who sed p or nt thContra,and
who contracts for such pojec¢with a contractors)licensed pursuant m the Comnnrh /
t�13\1 rtecchre law.
ampxcmPt under BAP ter Inca rcmnn
/--� W 1/ 1 a t� vim.
Owner' aro Dalc r '/
W K COMI'ENS '�rrO�N DECLARATION
71 hereby affirm under penally of perjury one of the fdfuwipg decluasi-ns:
JJ I bare and will maintain a Certificate C.nuutoself-iinsu�a for worker's Compere
sono..as provided for by Section 3700 of We labor Code,for the performance of the
wok for which this permit is issued.
0 1 base and will maintain Wmkvs Compcmmion h turancc,as mcpned by Section
PBI)of the labor Code.for Ne performance of the work for which this permit is issued,
nfy Worker's Com penration Insurance carrier and Policy number art:
Carrier: I'ol icy No.: _
CERTIFICATE OF EX EM PTION FROM WORK ERS'
COMPENSATION INSURANCE
(This suction need nut W cdmpincd lithe Ierm11 is for one hundrca dollars(Eltlp)
less.)
1 certify Wal in the prrfunnance of the work for which this Permit is issued.1 shall not
cord any
any mannef m az to Wcrim Subject the Workers'Compensation
La ICXrAsia.O m
,anti s� Ib 111
NICE TO APPLICANP�Ber making this CeniGcale or Exemption,you should
me subject to We Worker's Compensation provisions of be labor Code,you must
z forthwith comply with such provisions or this Permit shall W deemed mvoked.
z O CONSTRUCTION LENDING AGENCY
F+N" I hereby affirm that More is a construction lendingagency for the performane,,of
D4 Wr work for which this permit is issued(Sar.301 Civ.C.)
Is7 Q Lender's Name
Lender's Address
� z
V Q 1 certify that 1 have Toad this application and saa that the above information is
Caren,I agree to comply with all city and county ordinances and sum laws Loading to
Qv building c-nsweoon,and hereby aothoriae representatives of this city to enter upon the
ab-vc-meience,oned the grty amin institution for ureases.
F a (We)agree to save,indcmni fy and keep harmless the City of Cupertino against
D,, liabi lhies.judgments.costs and is genes which may in any way sector,against mid City
C) z in ronuyuence of the granting of this permit.
'—' APPLICANT UNDOtSTANDS
/ANN�p/.,WILL COMPLY W H ALL�IJON- NT Issued by: Date
SOURC�CLr NC fONSF'/ — Y I
/c,� /00"" Re-coots
Signtybrc of Ap C.mfe., Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ur future building.ccupanl sore or nitrate haraNuus mamoill
az reined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
C.dc,Se❑nior 15531(x)? Nd All roofs shall be inspected prior to any roofing material being installed.
Yes R
Will thea licant or future buildin Occupant use e t or ac„ces which If a roof is installed without first obtaining an inspection, I agree to remove
dt hes.ar0ms air contaminants u dcOncJ by the bay Arca Air Quality Managcmcnt all new materials for inspection.
Jisrin? !,a
❑Yes '.Ul'rtv .
I have read the haraNnus materials ayulremcn¢under CM1apmr 6.95 of the Califon
ria 1 l<althkSafcl Co:IC.SCLvrm15505.$53J and 255)4.1 understand Nasi the huilJing
dos rot a an a tenant,that it is my restnmsihility m notify 11 cupant of We
Let me w ' must me noiaswmce.ra CcrJ am of 6�pol Signature of Applicant Date
Owner horixed age I ` r m All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
4y. Cupertino CA 95014
,. Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
UPERTINO
Building Department
JOB ADDRESS- PERMIT
L/ cZ1 '7gZ,4V/Ni� Cly 7 7/ V
OWNER'S NAME: p p PHONE CF .7 T
GENERAL CONT CTOR: FAX #
I am not using any subcontractors:
1�'nL o
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
11171 dor Signature \Q Date
CITY OF CUPERTINO
ti OF
FURNACE/AC 6 Z
UPEI� TIN0 PERMIT APPLICATION FORM
APN # LG Z 7 Date: J
r L �� Lf
Building Address:
A( 0-7446dW Cf C 7 0 C4
Owner's Name Phone #:
i4Y , fo U �o T'� 0
Contractor Phone: License
I #:
e o ifs-� 0 a
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential Commercial ❑
a o R (rll2 � o Ald Z-14%x/
For Residential Installations:
Attic.❑ 1" floor ❑ 2"d floor❑
dhere to min set back requirement❑
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningApproval Re wired ❑
Cost of Project: Type of Construction: Occupancy group:
�d
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A 1V a'I Fee ID Fee Description Fee Grou
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 c$n MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUS C Business License BUILDING