05070066 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT ,CONTRACTOR INF.ORM TIQN y;
BUILDING ADDRESS:
PERMIT 1I0 5070066
21661 LINDY LA
OWNER'S NAME: PERMIT L96UE DATE
KEVIN YEN
ONE: SANITARY NO. CONTROL NO.
ARCHITECT NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=00 LICENSED CONTRACTOR'S DECLARATION
w Mosby affirm that 1 am liecmed under provisions or Chapter 9(commencing Job Description
with Section 7")o(Division 3 of the Business and Professions Code,and my license is
n� to full fame and effm. ADD A/C
'E License Class Lie.0
n F O Date Compacts,
7W ARCHITECTS DECLARATION
I undenund my plans shall he used as public servos
OyU
0 Licensed Professional
a OWNER-BUILDER DECLARATION
0 1 heathy reason.sect on I em exempt from Ne Comncmr's :Any c Law far the
O 0 which requiresa (Saban nil Ldi Business and improve,
duo um Code:Any city or county
m which ostium a e.irso p, ii.(e almn improve,demolish,a repair any structure
F i i
pd.,m its tensed .also moo ore t rovisc rs,if for mch ramam'm Gle a d.Loco suxmcm
s (bal heempoos ta,ivi pursuxm7")ofDivismn(ft aideBrumsandPrstlaw(Chapml9 Sq.Ft, Floor Area Valuation
(eat he Is seem it thomious and of basis
l aide al a ed exe and on.Any vi Code)iion of
that he u exempt thcrt0om and the baso(ar the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ef0 0 Occupancy Type
nor roam dun five hundred dollars(33(K).
❑1.as owner of Ne property,or my employees with wage as Usti, In compensation,
will do the work end the suucmrt is not intended ar altered roraaie(See 7061.Business Required Inspections
and Professions Code:The Camrmeacr's Lim.law does not apply to an owner of q p
propeny who builds or improves thereon,and who daeuuch work himself or through his
awn employees,provided thm such improvements are not intended or offend for sale.If,
however.lie building or improvement 4 sold within one year of completion,the owner.
builder will have lie burden of proving that he did out Wild or improve for purpose of
Ic.).
h as owner of lie property,am exclusively contracting with licensed eomaacmry to
convect the pmject(Sec.7066,Business and Professions Code:)The Comexmri U.
come taw onto not apply to in owner of property who Wilds or improved thereon,and
who contracts for such projects with a eonautor(s)licensed pursuant to the Contromwe,
License law.
❑I am exempt under See.��/7 ,B&PCI thisremon
verset / Dam_
WORKER'S 24PENSATION DECLARATION
1 hereby Kinn under penalty of perjury ave of lie following declarations:
❑1 have and will maintain aCer ificer a of Consent m add idnum for WorkersCompen-
sation,as Provided for by Section 3700 of the labor Code.for the perfa,manu of one
work for which this permit is issued.
❑1 have and will maintain Workers Compematlon Insurance,as disputed by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compemadon Insurance carrier and Policy number one;
Carrier. Policy No.: _
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This see iso need not becomplctcd little Permit is furore hundred dollars(SIBo)
kid.)
I cmtify that in the perfarmanec of Ne work far which this permit 4 issued.I shall not
employ any permit in any manncrmys mb�cp esubjauo the Work.,Compensation
Laws of Calimmia.Di— 5/ IZ/uyY
Applicant
NOTICE TO APPLICANT:If,afictriusking this Certificate of Exemption,you should
become subject 0 the Worker's Compensation previsions of the Labor Code,you must
.,z forthwith comply with such prnvitiam an this penait shall W deemed revolmd.
z O CONSTRUCTION LENDING AGENCY
[-� l herebywhich his
thatthemissued(See computationlendingagency,for the Performance of
a Ne work fur which this permit 4 issued(Sec.309'!.Civ.C.)
L[7 Q ndcrs Name
Under's Adddcss
0 z le
U 0 1 certify that I ham read this application and sum that the above information is
I3. correct.P agree to comply with JI city and county ordinances and sum laws relating to
0O Wilding construction.and hereby inthodn Mrssenutime of mu city to enter upon the
} ahuvcmentioned properly for inspection purposes.
(, 0. (We)agree to save,indemnify and keep humleas the City of Cupur ins against
fA liabilities.judgments,consand expenses which may in any way sttnc against said City
t.)z in conseganco of the granum,of this permid.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date_?---�2_f
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaH Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will me a Cupent or(Muni Municipal
Cb e.Chant uorc or hmollc M1azudousd Sole)l
C icfined io me Cupenina Municipal Cadc.Chapmr 9.13.roti the Hcilth and Safety
Code,Section 25532(a)? 1All roofs shall be inspected prior to an roofing material beim
❑Yea P P Y g g installed.
Will the. licant or fudun buildin sap ant pre a If a roof is installed without first obtaining an inspection,I agree to remove
pp b p o Air Quality
or Marta which g
emit hazardous air comnminanu u defined by the Bay Arca Air Quality Management all new materials for inspection.
Diuriet? T�p�
❑Yes 'Pl/
I have sal the hvardnusm iworareyvi¢menu untbr Chapmr6.95 of the CaGrm.
n4 Health&Safety Code,Seeuom75505,I5533 end25536.I undersund Waifthe Wilding
does rot currently haw a amant,Nat it es my retpommility to notify floc meupernt of me
rcyuimmcnuhichmusLbcmc 'auoissuanceof-ccoam"mofOccup T(2g v� Signature of Applicant Date
f
Owner All roof coverings to be Class"B"or better
Fr agent Dam
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35622016.00
DATE ISSUED. . . . . . . : 07/12/2005
RECEIPT #. . . . . . . . . : 30328
REFERENCE ID # . . . : 05070066
SITE ADDRESS . . . . . : 21661 LINDY LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KEVIN YEN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4807
RECEIVED FROM . . . . : KEVIN YEN
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
s
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BRE14AIRHAN NO.UNITS 1.00 10.26 0.00 10.26 0.00
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0.00
BSEISMICRE VALUATION 2,200.00 0.50 0.00 0.50 0.00
PPERMITFEE FLAT RATE 1.00 38 .37 0.00 38 .37 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 160.73 0.00 160.73 0.00
METHOD OF PAYMENT AMOUNT NUMBER
OTHER 160.73 MASTERCARD
------------
TOTAL RECEIPT 160.73
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
z 166 1 1,IXDIV LA M51 os-u --7 go �
OWNER'S NAME: tCCV IAI Y61,-) PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Situne Date
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
(2 o1�—
Owner/C ctor Signature Date
CITY OF CUPERTINO
•& FURNACE/AC
• CUPEt�TINO PERMIT APPLICATION FORM �S&)
APN # 3 Jam/ � a b/� Date: 7 / (2/0
Building Address: �P `
zIb6i L( NDY LA-Ne
Owner's Name: lice v/�j YCAj Phone #: y C4- 9 7 3—f ?v()
Contractor: t�r� License#:
Cs->2G u� -F1� v�(
Contact: CaTt-er,rp Liu Cupertino Business License #:
Building Permit Info: +,Id(1� A/C f,�-3 /196u,v-d S' F',.t SNha< &
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: a d dA C—
Residential /f Commercial ❑
For Resi ential Installations:
Attic L14 I` floor ❑ 2"d floor❑ /
AOL Adhere to min setback requirement[_�/
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project:$7, -2-00 Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cfim MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
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
BUSLIC Business License BUILDING