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05070001 CITY OF CUPERTINO BUILDING DIVISION PERMIT i,CONTRACTOR INk'URMATION .. BUILDING ADDRESS: PERMIT NQ.V 5 0 7 0 0 0 1 2 OrER'S NAME: PERMIT LSU2 DATE KEVIN YEN PHONE: SANITARY NO. - CONTROL NO. ARCHITECffENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a a a a MetzLICENSED CONTRACTOR'S DECLARATION F❑ 1 Wreby affirm that I am licensed under provisions of Chapter 9(commencing Job Description =W with Section lOR)of Division 3 of Ne Business and Professions Cade,and my license is ,�= Dn full mm<ana arms ADD ELECT. SUBPANEL/LITS & venseClms Lie« SWITCHS/RECEPTACLES @ HEN f Dam ComDECL Jt((TT (' e ARCHITECTS DECLARATION �5 p I Y W U I undcrsunJ my plans shall W used u public records N(,ps�ilY tryJ�g a C Licensed Pmfussional OWNER-BUILDER DECLARATION . 0 I Wmso affirm on 1 am exempt from the Contractors License Lintcity for the _(m— �Jy �I [ p o following reason.l5ecuun 8131.5,Business and Rofcssinns Cutlet;Any city¢county / b I r 2005 <m which requires a Permit m construct eller,improve, hroolish.err¢pair any structure Lei prior to its issuance,also requires the applicant for such Permit to file a signed sutcment C < that he is licensed pursuant to the provisions of the Contractor's Licenm Law(Chapter 9 Sq.Ft.Floor Area Va C 500 or (commencing with Section 70(K7 of Division 3 of Ne Business and Professions Coda)or gat i $ that he is exempt therefrom and Ile basis for the alleged exemption.My violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number ee ane T .or more man eve hundred dollar 35622016 . 0 0 P y YPe ❑I,ns owner of me propcny,m my cmploycu wire wages u Nati rete compenmtlon. will do me work and dooswewo;is not intended or offered for sae(See.10/4,Business and Professions Cade:The Contractors Lkeme Law docs not apply to an owner of Required Inspections property who builds or improves thereon,and who doeuuch work himself Or through his own employees.provided that such improvements are not intended oroffert4 for sale If. however,the building or improvement is old within one year of completion,the owner builder will Mth Mrs ons Widen of preving that W did not build or improve for purport of of sato.). C]1,as owner of the propcny,am exclusively contracting with licensed contsaztors in cowmet to project(Sec,8144,Business and Professions Cade:)no Commuter's Li- come Taw dors not apply m an owner of pmpcny who Wilds or improves demon,and who contracts for such prejecu with a contractors)licensed pursuant in IM Contractors License Taw. t]1 am exempt under Sec. .B&P C for this won Dale WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one or the fallowing declarations: ❑1 hsm and will meinuin a Cerufiaate of Conserv to ul4insurt for Workers Compcm sation,ns provided for by Section 37M of the Labor Code.for the performance of the .,it for which oris permit is issued. ❑1 have and will maiman Workers Compensmim Insurance,m required by Section 3700 or the Labor COM.for Ilse performance of IM work for which this permit is issued. My Worker's Compensation Insurance canicr and Policy number art: . Carrier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not W completed lithe Permit is for one hundred dollars(SI00) or lcm,) I comfy mat in the Performance of the work for which this permit H lamed,I shall nut employ any penin in any manner,sn ys toMzome subject m me worken'Compensation L,ws of California.Daley I Y Applicant 1le.v ,\f N - -' NOTICE TO APPLICANT:If,aft r making this Cord I ate afar Exomp,ion. become subject in the Worker's Compensation previsions of the Labor Code,you must ,7 O :oMwith comply wit such provisions¢tris permit anal[W decried revoked. Z''-' CONSTRUCTION LENDING AGENCY P4 I Mrchy affirm that there is aeons him broiling Agency for tWpmfmmamc of CL 7 the work for which this Permit is issued(See.3091,Co.C.) Vl Q Itn1cr9 Name Undets Add. V Q 1 modify that 1 have mad tis application and sum ren the mors infonnatiun is Fcancer I agree in comply with ill city and county ordinances and sum laws relating in 0(.J building construction,and hereby awhorim representatives of this city to crier upon the atnow-mentioned propeny for inpceuon pugtoua („�y (We)agree m save,indemnify and keep harmless the City of Cupertino against pl liabilities,judgmeau,costo and expenses which may in any way accrue against mid City CJZ in eotsaegmme of the granting of this permit ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGI1 �°jH� (t/o(' Re-roofs I. Signature of ApplicanUConuusor Dale HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will tM applicant Or future building Occupant store or handle hmasdous material u defined by the Cupenino Municipal Code,Chapter 9.12,and tho Health and Seery I.Sem..zss3z(an' All roofs shall be inspected prior to an roofing material being❑Yam ped' P P Y 8 g installed. W0l the applicant or future building occupant use equipment or devieea which If a roof is installed without first obtaining an inspection,I agree to remove emit hovardous air romamiouts As Jcfincd by the Bay Area Air Quality Minagcmcnt all new materials for inspection. District? ❑Yes ONa✓1 I have mad the hammous materials requirements under Chapter 6.95 of the Cabin, ma Health&Safety Code,S=.25505.25533 and 255N.I underused this ifthe Wilding does Out currently host a tenant mat it is my responsibility to notify the occupant of the mgoimmcma which met poor to lmaanm or.ccrufice,of eau�tlp er Signature of Applicant Date � o Owner ser aumoriacJ ascot Date All roof coverings to be Class "B" or better v revoi I C/j Step�oklte S(A Oo ��D�C� �Op� - , - • 2w &(o 1 1,1/V y 6AIVC JUL 12005 V Alt) CA q 5vt C) -7 5 12-1-124 161/2+161/2 18 18 16 1/2 16 1/2 15-4- 1 15 lql�12 18 F_ �o 1/2 18 10112 36 16 t 6.�00 1/2 10 112 15 15 11 6,112 -- E co E Qco 01 C) -01 ml C:) Q + sia ► , ui 0 10) 4—J _A cc co T 9 mo RILL T m � 0 C: mo E5 erg L erg i ® CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng : Sub: Blk: Lot : APN . . . . . . . . : 35622016 . 00 DATE ISSUED. . . . . . . : 07/01/2005 RECEIPT 4 . . . . . . . . . : 30198 REFERENCE ID # . . . : 05070001 SITE ADDRESS . . . : 21661 LINDY LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : KEVIN YEN ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4807 RECEIVED FROM . . . . : KEVIN YEN CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . , • TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - --- ---- - -------- -------- ---- ---- -- BPERMFEE VALUATION 2 , 500 . 00 83 . 16 0 . 00 83 . 16 0 . 00 BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00 BPLANCHK PERMIT FEE 1 . 00 83 . 16 0 . 00 83 . 16 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BSEISMICRE VALUATION 2 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 ELECTRIC SQUARE FEET 165 . 00 13 . 20 0 . 00 13 . 20 0 . 00 -- - ----- -- --- - ------ TOTAL PERMIT 253 . 25 0 . 00 253 . 25 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER - ---------------- - ----------- ---------- - CHECK 253 . 25 847 TOTAL RECEIPT 253 . 25 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 WJP TY OF O Fax(408)777-3333 Building Department JOB ADDRESS: PERMIT #0-�-d7 0 D O I •7-166 1 L ND Y L-,F}/vl` OWNER'S NAME: LC—V/N -nl PHONE # �y-nil 3 y j pp GENERAL CONTRACTOR: S C I A FAX # U4 5 S`16 2 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information 60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing %/ Electrical &v^a i'd /"awctn 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/Con or Signature Date CITY OF CUPERTINO CITY of PERMIT APPLICATION FORM ® CUPERTINO APN # Building Address: -21 (J6 ( L(/Ul> L Mailing Address (if different from building address): Owner's Name: VIN Yi✓N Phone#:-65-0" 7e1c/-s- 70�-G Contractor: License #: G va ted -D14V-nvr- jo✓v aU�-�3 Contact: - Phone: L/Oe 255 -Y088 Cupertino Business License#: CGS t1erov- Z-il4 Fax: yo5' -2SS-yo" Building Permit Info: 14IZ41 "00/y41, tee-zio +,SW,} Pes,,elect sr-&Or Bldg ❑ Elect N-1� Plumb ❑ Mech ❑ Job Description, Residential iy Commercial ❑ Sq.Ft. Floor Area: /65- St F� S/Sq.Ft.: Cost of Project: Z Occupancy Group: di Type of Construction: Please check this box if the project is a VN TZ-S second-story addition: ❑ Project Size: Standard Y" Large ❑ 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 1M 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 <= IOOOA ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 � � � 2S— aCITY OF CUPERTINO 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 hent Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg 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 Rei a Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alf of Drain & Vent PLUMBING BPWATER Instalt/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 efin MECHANICAL BREMAIRHAN A/C Units <= 10,000 efm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > IOK 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 BREMPOWER Power Device/Apparatus ELECTRICAL BRE MRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood. MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 F CITY OF CUPERTINO CITY OF - PERMIT APPLICATION FORM CUPEIZ,TINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Mar uee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Seb Specific Plan BUILDING BSEISNIICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERDIITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3 of 3 /I