06080172 CITY OF CUPERTINOR0I
BUILDING DIVISIAON PERMIT a CONT TO �F'O
WRIVr
BUILDING ADDRESS: NATIONAL CONSTRUCTION RENI Pffa§B`ND'06080172
21820 LOMITA AVE
OWNER'S NAME: PERMIT ISSUE DATE
HONG-HIM LIM 1355 FILIPE AVE QR/22/2006
SANITARY NO. CONTROL NO.
(818) 221-6057
ARCHITECTYENGINEfR: BUILDING PERMIT INFO
'BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
robx+ 1 hereby affirm ti s,1 sm licensed under pmHsiom of Chapter 9(commencing
I< with Section 7")ofllivlaion 3 afd,c Businessland prorcomm Codc.and my licensee
:may 4.full in.andeRam. TEMPORARY POWER
,pz uceme Class I3e.11 /J
iFG Dem ma
7 ARCHITECTS DECLARATION
on shall ux
1 undcraunJ my plans ed ses u public rtcorW
,
'c Licensed Pmfessianal
l y� Oat I am exempt f DECLARATION
Contractor's
ON
1 hereby affirm OW I am exempt from the RATIONr]Lkeese Law for 4e CZ'
a O following mason.(Section 7031.5,Business and Pmfessium Cade:Any city or county
which requires a Permit tocanatrta4 altar.arrow,dcmmLsh.or repair any atmnure / $369
Prior to its issuance,also requires the applicant formch permit to rile a signed Moment
c
that ae licensed pubescent W Ba provisionsof Be Cance$Lkara LAW compact Sq.Ft.Floor Area Valuation
{�$ (commancing wish Section 7000)of Division 3 of We Business and Paufm¢(am Code)or
Net he is eumpt therefrom and Use base far to alleged exemption.My violation of
Section 7031.5 by any Applicant far a Permit mbiecu the apPIICMI to a civil penalty Of
T Occupancy Type
not more than fsw hundred dellen(5500).
C 1,as owner of tie property,or my employees with wages our Weir auto compensation,
will do don weds,and deawcmre a not intended oraRered rameln(Sec.7043.Bmircu Required Inspections
and Pmfearroue CedeTh
: er Contractors LicemnsC Low does ant apply Ice an owner of q P
property who builds err im prows ttesrnn.and wM doea such work himself ar through he
awn employes,provided tatmuch impmwmenu mc nut intended roRered(arsale.If.
however.the building r imp nwment is mid within aro per of cnmplmim,the owner-
builder will haw she burden of proving that k did Out bWld Or improve far purpoe,of
cal.). .
3-K.awnr of We pmpcny,am exdusiwly comnning with licensed contractors to
construct the prlett(Sec.7044,Business and Pm(essioes Cade)The Comtactors U.
came Law docs not apply In an owner of propeny who Wilds or Improm Wereon,and
who contracts for such projects with a mntrnorts)licensed pursuant to We Contrmmh
License Law.
C l ren exempt under See ,B&P C for the reaaue
Owner
— Bit
WORM'S C6mPEbsAnoN DECLARATION
1 hereby arm under penalty of perjury,me of the following declarations:
I ham and will maintain A Cardfesno ofC.not nt to self-imum far WorkersCompen-
union,u pmuided far by Section 3700 of We Inbar Cade,far the performance of the
work for which this permit is Issued.
C 1 haw and will maintain WmWs Compensation Inmnna,u inquired by Section
37M of the Mbar Cade,far the performance ofthe work for which We Permit is issued. '
My Warkera Compemation resonance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut Mcompleed trust permit is frane hundred dollen(5100)
or less)
I cenify that in the performance of the woh far which this permit is issued.l mall act
employ my N.in my mmMr breCrnC mbjcci b the Worker(L'omicM1mdon
IAwaar C_ifomtgpc _2 olm
NOTICEt 7Avv/
NOTICE TOAPPLICANT.If.after Compensation
this previsions
of Labor Cod youshould
brume subject y it Wort pr s sorthis
er lit mai obe she Mbar Code.you most
.J O forthwith comply with such provisions or the Permit rhell W deemed revoked.
'z tiCONSTRUCTION LENDING AGENCY
(..m (hereby affirm that them is A construction lending agency for We performance of
IWthe work for which the permit Is issued(SCA 3097,Civ,Cd
dQ Lenders Name
w'7 E lenders Address
U Q 1 certify that I haw,mad this application arta slow that the show information Is
ty F came,.I agree to comply with aft city and county onfinances and sue him misting to
0 U building construction,and hereby authorize mprcsenutivcs ofthis city to enter upon the
�I37 above-memiuned pmpeny fur inspection Pugees.
pyo (We)agree to taw,indemnify and keep humdall the City of CvPCoino against
rte.,l'A Ilabiliues,judgmenu,costs and experem which may in any way acerin agamotand City
U,'Z in corcqucncc of the granting of this pannit. n q /
'•" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Q'—�fl-1 q-
SOURCE REGULATIONS.
�L$4 Re-roofs
Signatum of ApplicenuConuamor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building rccpanutare or handle bawNam manorial
u&fl.cd by to Cupertino Municipal Code,Chapter 9.12,and the HOMO and Safety
Cade,Socuon 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
ED Y. ON.
Wit the applicant or ru Ism building occupant=equipment or deocs Mich If a roof is installed without first obtaining an inspection,I agree to remove
emit anNom air nemamimnm as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
CYes VjNo
I haw mad the heurdnus materiels requirements under Chapter 6.95 oftie Collins
nla Hcalsh&SafciyCade,Sccdm25505.25533ad25334.1undcuundthulftita Wilding
does net currently haw a nonan,that it to my responsibility to notify the occupant of the
myuirements which most be m a ren ivaatme ancenirta.taara ener. Signature of Applicant Date
�.p � g 7vlbb
Ownerrauthorucd agent Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
(4' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
#UPEkTINO
Building Department
JOB ADDRESS:a�y,�o PERMIT #
CA
OWNER'S NAME: PHONE # -
GENERALCONTRACTO . ca,-e.axFAX # f-d-7 738i
I am not using any subcontractors:
Signature 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
Owner/Contractor Signature —Date
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35715008.00
DATE ISSUED. . . . . . . : 08/22/2006
RECEIPT #. . . . . . . . . : 35709
REFERENCE ID # . . . : 06080172
SITE ADDRESS . . . . . : 21820 LOMITA AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HONG-HIM LIM
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CLARA LIM
CONTRACTOR . . . . . . . : NATIONAL CONSTRUCTION RENTALS LIC # 22537
COMPANY . . . . . . . . . . : NATIONAL CONSTRUCTION RENTALS
ADDRESS . . . . . . . . . . : 1355 FILIPE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95122
TELEPHONE . . . . . . . . : (818) 221-6057
IRE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
______ _____________ __________ __________ __________ __________ __________
BTEMP FLAT RATE 1.00 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 100.47 0.00 100.47 0.00
METHOD OF PAYMENT AMOUNT NUMBER
____________ __________________
OTHER 100.47 VISA
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
•
CITY OF CUPERTINO
C TEMP POWER
4fUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
a/P.Zo LC-4 Ifoi
Owner's Name: Phone #:
Contractor: ss � /p/ Phone: License #:
Alaiffnd,c Yu el&' 4,..�ad�o
Contact: Phone: Cupertino Business License#:
Q Se Ma
Building Permit Info:
Elect ❑
Job Description:
Residential Commercial ❑
Cost of Project:
36 _
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
•