04040051 CITY OF CUPERTINO
BUILDING DIVISION
PERMIAh �C�UNTRACTORINF'012M�TN
PERMIT NO. '
BUILDING ADDRESS: o4040051
922 TjRP.RTV (-T
1'0tnff[L4TIE DATR
OWNER'S NAME:
JEN KAO
SANITARY N OL N0.
NE
BUILDING PERMIT INFO
ARCHI7ELT/ENGINEER: BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 i meby affrrm Ns 1 am lio ued under providoes of Chapter 9 memmexing
"S'
We 7W)Of Dlvbian 3 of the Busiuu and Profasaions Code.and my license is
in full force sw,Em, DEMO SWIMMING POOL
vJ� Licensechis Lic.m
Dau Convector.
ARCHITECTS DECLARATION
I underrated my plate still M used As public records
Licensed Profcsaiansl
OWNER-BUILDER DECLARATION
1 hereby,Ilton on I 1 exempts An Ipr Canvumr's License law for my
O D fallowing mama. emit I ]8313,Business and oo.deaf0ns Cod,:My city m comity
$M whore Iryussu a Permit re censure,alar.impose,dammed,ri mryli anY manure
M
primmiucensedc=.requlme Marham forsuch tho Contractor's
NeaslgmAsaumcnt
3a NadMlsliccnscdpurmsnuoNcpovialonso(NeConuuarilhce""LAW(CMpm9 Sq.Ft.Floor Area Valuan n
(commercial wish SeNon7")aDivision 3 or the Business and Professions Code)w
dm M h attempt therefrom and the basic fm the alleged assumption.Any vlolathm of MO
y1w.��
noted ti ore ONan Rbby mydrtd ddtsn r a permit
r it subjects the Applicant m A cMl penally of - 3 AM 1W @ CT 0 0 Occupancy Type
❑L u ownm of do pmpeny,re my mploy es wide weguu Netrua eompenudon,
a
will Pr NC Want and dees a ctureComma Cres Leded LAW dos not Apply 706/,8"Ar Of Required Inspections
and property hobu Code The Conauon,Liana law dors not apply lf rt owner of q P
_D solo
mplo b,pmAed ftt thereon,Aedwho
umnaue=de4orafremdfthrough lf.
caro ewloyms,provided Nat nee im ismemmu ase not year
ofe oro@red the mar a.
hoaresv,the building or ImPrownwu ts sold wlNa one yens of mmPlrsion.the owner-
builder will base Ne burden of paving Nu M did not gild or impmw for pumas:of J
Y sea.). s
1,u owner of me property,am exclusively contracting with ficaued conuamou m w��
num tie Pmjea(See.7044.Buaimss and Po(esdma Code:)The ConOas m 3 Li-
cense few does nm apply m an owner of PrOPvnY w'he Milds of lmpoves demon,me
who conuacu for such projects wide as nuanons)licensed paramount to the Contrumr'a
License Law.
❑l em exempt under See. .B k P C for this reason
rr--�Uyg_I PSNSATION DE tau
I - WORKER'S M SATION DECLARATION
1 hemby afihm under penalty of perjury one VLdeOO owing Mansions:
W.and will mainwe•cardimaa or Conant to selFinmm fmwoNeeseompn-
as Provided far by Section 37M of the Lebon Cod,for use poor..A.of the
rk for which this permit is usw4.
❑1 hoe and will maintain WmMr's Compeuhon Who snce,as required by Section
37M of Ne labor Code,for use perfmntame of the work lmwhich this Permit is anted.
My Worker's Compensation Insurance carrier And Policy number are:
c m w.. Policy No.:
CEKIIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tab senlon need not rtecnmplead i(me permO la fmonehundred dollars(SIM)
m Iesa)
1 scoff,dot in the puronnence of the work for which this Permit is issued,l shall not
employ inypermn in any mesncrm as In become subjaCl 101M Waflaus CamPenution
Laws of Califomie.Data
Applium
NOTICE TO APPLICANT:If,afar making this Cenlneste of Exemption,you WuW
bmome subject he the WorkeM1 Compensation pmvia10 of dee labra Care.You mut
0to
fowith comply with sm M ash provbions this Permit all counted rewked.
r~y. CONSTRUCTION LENDING AGENCY \.
1 hereby eRrrm Nat Nem is a cormorclon lending agency for de performamre or
�i
the work for which this permit is issued(Sec.3097.Or.C.)
a 0 Lemices Name
]z LeMer's Add¢u
)R 1 certify Nal I have read Nis applicadon aM sum dud me,b0ses infomeationb
L U cortex I agree to comply with all City and Murry mdnuandm
ioasea laws hting m
SV'
Wilding construction.and hereby mmodm representatives of this tidy to enter upon she
r above-mentioned pmpcny for Impaction purposes
y gy (We),gom to un,Indemnify and keep hanOleu the City or Cupertino against
to
liabilities.Judgments,cuu And upcmcs which may in any way..against said City
in
APPLLIICANT UNDERSTANDS ANeence of the licensiof thisD WILL COMPLY WITH ALL NON-POINT Issued by: Date
S CE EGULATIONS.
c Re-roofs
gaustruclarApplican .'"ressur u
HAZARDOUS MATERIALS SRH
Type of Roof
SU
Will the applicant or fuwre building Occupant more or handle hazardous material
As defined by du Cupertino Municipal Coen.Chapur 9.11,and the Health and Safely -
Code.Section 25531(,)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes kYNo
Will the applicant at funnture building Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
1 h,vsomes air contaminants a defined by me Bay Are,Air Quality Management all new materials for inspection.
fict7
❑Yes No
I haw read the huudme materials requimmenu under Chapter 6.95 of the Califor.
niaHealth k SaietyCodc.Sections;25505.25533 anal 25534.1 umarmaed Out if Ne Wilding '
docs not concert Aew a amen,that 11 b my responsibility to sooty IM Occupant of the
ret cots NmmaatMmmpriar ,' anMaaCtina,aaraMp Signature of Applicant Date
owns ter.adearimd agent Date All roof coverings to be Class"B"or better
• •
CITY OF CUPERTINO
0m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN 35611069 . 00
DATE ISSUED. . . . . . . : 04/08/2004
RECEIPT 4 . . . . . . . . . : 25120
REFERENCE ID # . . . : 04040051
SITE ADDRESS 922 LIBERTY CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JEN KAO
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4018
RECEIVED FROM . . . . : JEN KAO
CONTRACTOR . . . . . . . : LIC #
COMPANY
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE
SEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ----------
__ _
BPERMFEE VALUATION 3 , 000 . 00 77 . 00 0 . 00 77 . 00 0 . 00
BPLANCHK PERMIT FEE 77 . 00 65 .45 0 . 00 65 . 45 0 . 00
BSEISMICRE VALUATION 3 , 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
TOT ---------- ---- ------ ------ ----
AL PERMIT
142 . 95 0 . 00 142 . 95 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
---- ------------- ------------ - -----------------
CHECK 142 . 95 3108
TOTAL RECEIPT 142 . 95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
704 DEMO
-------- -------
•
• CITY OF CUPERTIPW
DEMO �D Cil DOS'
CUSPEkTINO PERMIT APPLICATION FORM
• APN# S,6 tq � 6 Date: 7/01/04
Building Address:
Q22 �.l�py C� Cz�
Owner's Name: N K A m Phone#:
Contractor: License#:
Contact: K� Phone#:
�8 zsr- 6966
Ap licanVContractor: S
!esidential:
uilding Pe it Info:
d LEI/e;' (Plumb) Mech
b scription: Oemc to-n of a -.w;mm;Kl PW
00 Commercial:
Sq.Ft. Floor Area: 3"l S 5Q.Fi-• $/Sq.Ft.:
000 6p
Architect/Engineer: Valuaty
Type of Construction: Occup/ cy G oup:
•
Qt 'f
Appficible Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
• A. V All the work authorized by this permit
B. A portion of the work
C. _ None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # nse # Type of work to
do I low- LG C_fV1rme4
jr
l/
C �u
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
_performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: zeG K -c Date:
Job Address: ^92Z Lr b?a 7�Y Cf .lf/Gd Permit# o q::,:67-q
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
•
City of Cupertino Building Department
CITY 0f 10300 Torre Avenue
CU PERTINO Phone: (408)777
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensations
contributions.
Thee may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the US.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or,
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performming
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in youfcoammunity or at 1020 N Street,Sacramento,California 95814. •
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned. i
Very truly yours,
Building Department,
City of Cupertino •
Printed an Recycled Paper
CITY OF CUPERTINO h + `°'•%'�'' �."^ ,
BUILDING DIVISION PERMIT ^ C01�TRAC�'TOR INF-OItMPTION ;•,
BUILDING ADDRESS: PERMIT N0.
04040051
R'S NAME: PERMIT nxrm DATE
JEN KAO
E:
SANITARY N OL ND.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
op LICENSED CONTRACTOR'S DECLARATION JobDescri ti�asaaaa �eI5s/Aya�san�{ P`��
r�ty I Wreby affirm Net l am licensed under pmvWou of Chapmr 9(commencing P ■ O Y V� 6r'v LE D
n� with Smtien]IXD)o(DiHsion7of the Budwuand Nomssionc Code,and myliccnse is
J2pin full force ondclfect. DEMO SWIMMING POOL
License Class Li`."
Dam�Contractor MAY 13- 2004
e0 s-W ARCHITECTS DECLARATION
Y ]1 l trimmed my plans shall he used as public records 9 ryep�/�
o Licensed Prefcammind BUILDING
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contours License Law for the
E O C following mason.(Section]1131.5.Business and Professions Code:Any city or county
$ which mqulres a Permit re cnnmruck slier,improve,demnlud.or mPilr any sanctum
F�< prior to its issuance.she requires Ne applicant for ouch Permit o file a signed mummer Gee
mm that he is licensed pursuant to the provisions oftheContractors License Law(Chapter 9 Sq.Ft.Floor Area Valuate n
FS (commencing with Section 71)[a]) asand
O)of Division 3 ofthe BusinsProfessions Cede)or
ui
.. dbe h exempt therefore and the bash for the alleged exemption.My violation of
Section 7031.5 by ".pplicant for a permit subjects the applicant o arnd penalty of 39a Si`I9M4ef 00 Occupancy Type
not mom Nan live hundred dollars($507.
❑I.as owner of the property,or my employes with wages as thea role compensation,
will do the work.and the weamm is not intended or offered forssle(Sax.7W,Business Required Inspections
and Profusions Cade:The Communes License law does not apply m e ns an owner of q P
property who builds or improves Iheroon.and who does such work hi msel f or through his
own employees.provided that such Impmwmanu art not intended oroffered Fomes.If.
however.the building m Improvement Is sold within one yearof completion.Ne owtsr-
bullder .will have Me burden of proving that W did net Wild or Improve for purpose of
Y tile.).
I.as owner of the property,am exclusively coulrecting wit licensed contractors an
o struct the project(Sec.7064,Business and professions Code:)The Contractors U.
cause law docs not apply to an owner of property who Wilds or improves Mercer.and,
who contracts for such pmjeeu with a eontramor(s)licensed pursuant o rite Connector's
License law.
❑1 em exempt under Sea B&P C for this reason
yt---l-sec--s..t f i`--Y{iV� —Dam
WORD' K�MP9 SAGONDECLARATION
I hemby.loom under penalty of perjury one tsL ds4caring declarations:
mil 1 have and will maintain a CW flcete of concent to self-insure for Workers Compem
orlon,as provided for by Section 370 of the labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance as required by Section
370 of the labor Code,for the performance of Ne work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Curiae. Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This it.need not W completed Rthe permit is fora.hundred dollars(S10)
or less)
I ecoify that in the performance of the work for which this permit Is issued.1 shall not
employ any person in any manner m as to become subject to the Worker[Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ceniraate of Exemption,you should
become subject to the Worker's Compensation provisions of Me Labor Code,you must
.�,Z, forthwith comply with such proviainns or this Permit shall he dcemed rooked.
z'O CONSTRUCTION LENDING AGENCY \
H I hereby alarm that them is a construction lending agency for the performance of
a the work for which this permit B Word(Sec.307,Civ.C.)
Ie1 Q leather Nurse
G Lender's Md.
fJ Q 1 ectudy that 1 have reed this application and sum Nu the above information is
correct 1 agree an comply with all city and county eminences and sus laws misting in
Q V building construction,and hemby authorim representatives of this city to enter upon Ne
W shove-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
cn liabilities,judgments,coca and expenses which may in my my accrue against said City
IJ 7 In consequence of the gmming of this permit.
rr APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 CE EGULATIONS.
_ a Re-roofs
gra o Applic tor HAZA DOUS MATERIALS SURE m Type of Roof
Will the applicant or forum Wilding eceupant mom or handle huamoor material
de r by the Cupertino Municipal Cade.Chapter 9.12,and the HhilN and Safety
e.Sather 2ss32(a)] YNe All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hannious air conmminana a coined by the Bay Area Air Quality Management all new materials for inspection.
District? ✓✓✓✓✓✓
❑Yes No
Ihaw mad Ne hammnus materials reyuimmenu under Chapmr6.95 of the Califory
niceHealth&Safety Ce .Sadou25505,25533md25534.1un&mrsta mirMe Wilding
dues not currently how a tenant,that it is my responsibility m wily the aceupant of the
m cru nice mustWmetprior ,' when aCcniRcam ar t3ccup Signature Of Applicant Date
owns an,atha red agent oars All roof coverings to be Class"B"or better