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06050067 CITY OF CUPERTINO ^ _ + ' '"o'-- 0, G DIVISION A..PERMIT BUILDINGCS1VT.l2A. ' OR INFO'RMATIU «�r r'uk_:B,3,r'altrsf< a Ap!2 BUILDING ADDRESS: s LI ' S CONSTRUCTION PERMITNo.06050067 21915 LOMITA AVE OWNER'S NAME: PERMIT ISSUE DATE LUMIN CHANG 654 8TH ST 05/09/2006 E: _ SANITARY NO. CONTROL NO. (510) 261-8826 ARCHITEC(ENGINEER: BUILDING PERMITINFO BLDG ELECTO 1OM O Ipp LICENSED CONTRACTOR'S DECLARATION lob Description i I anarchy 4rEw Nat r w under licamcd pm,im m of Cammor 9(comncing me vide Section 7000)of Division 3afdm Busiaan and Prollmiom Cade.and mY[I--is n in full Iowa And effect. INSTALL TEMPORARY POWER POLE jJZZq Dam Dow Clm comY 347 ARCHITECT'S DECLAMTION I undermand.my plans shall W used u public rtcorde r �Oln Lkemed Prefmfessbnu J m� OWNER-BUILDER m Ce Conte ON /O/ 0 9 1 hereby.(Siam that 1 1. exempt from Ne Cssions o :My c Law o far to v a O fallowing mama.(Saito 7051.5,Busiaas and Improve. de um Cade:My city or county 5$An which imissuaPermite.Aw recamtnmLaper.improve.hermit t,rie a sig anyavumure 3 00 I�, thin rbiuiensedpalmentto nu pre inion o for amprarmr's Lia saigded statement �g thathmemi gwithSrwmttothcpmvivision the oftheBwwr'anmmclaw(Chodc 9 Sq.Ft.Floor Area Valuation $ thohe Is engwiNSectfon7 send the Divisionr of Neeged els and empton.my viCoh)of — Nu k m eswPt Naefmm slid Ne bast gar Ne siteged uwptlm my violent an of Section 7051.5 by any applinnt Inr a Permit subjects the applicant m a Civil Pew1tY of r Occupancy Type not mom than five hundred dollars(55001 ❑1,u awoer a(0te property,a my wployw vIN wage u Nepmk tampematim. will do the work,and Ne avuaurt Is not Intended a oRwd wasam(SM.Tie.Busiws and Prefessiam Cade:The Controllers Lkuoe Law does not apply b an owner of Required Inspections pmperlywho builds afmprow Nerom.and whodoesaahmall himealfar drawls his own wplayea,provided was such Imprommmu Are cot Intended aellured(anis.B, Wenner,Ne buildingar impmwmmt is mid within am year o(oempm W.An awrmr- builder will have the WNen of proving Nat he did nm build or Improve for purpose of sok.). '(W 1,As ow.of ted property w esdasiwly cwuwsag wide licensed wntncmn an . romtmm the pmjem(See.7044.Business and Professional Cade:)The Contrawra LL annual law dean not apply an an owner of property who Wilda or Improves thereon,Md. Who contracts far such pmjecN with a canu9ebr(s)BcelnCd punWnt an the Cotbmmra Lima law. ❑1.... 1 denSec .B&PSC far rOil lm_ssoanv Owner—i LLLe'ua-- a-rl Dam 5 %O WORKERS COMPENS ON DECLARATION 1 hereby afferent under penalty of perjury ane of Ne fallowing declarawne: 1 ham and 5001 maintain aCeWBou of Comment in self-edam fa WorkersCampen- ndon,As provided fa by Section 3700 of Ne Labe Code.fa the performance of Ne work for which this pewit is imoad. C I Nve and will maintain Worker's Compensation Taman,As mquind by Section 3700 of the Labor Code,for the performance a(Me aware fa which tills pewit is land My Workers Compensation lmunnce airier and Policy number w: Carver: Polley No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE v (This western mond noted completed if Ne pewit is foram hundred dollars(5100) or less) I certify that in the performance of tiro work fa which this pewit Is issued.I shall tot employ any person in my mmwrm bbce mbj �q�e Workers'CompemWon Laws err CulramiL Da ,! " Applicant 'u soul NOTICE TO APPLICANT`.IL after making Nis Cenlficam of Exemption,you shaub became subject in the Worker&Compeantion provisions of Na labor Code.you mute vJ 0 forthwith comply with such provisions An Nu pewit"I he domed revoked. Z y CONSTRUCTION LENDING AGENCY [-t Iherehy affirm that then is a construction lending agency for Ne performance of G'> the work for which this permit is issued(Sac 5097.Civ.C.) ' 4 Q Lenders Name ,J z Lenders Addmss t.)O 1 certify that I haw read this Application and state that the above Information in ly cower esordordinances;mb 1 agcomply with all city and county ordinances; sum laws nixing t" O V building construction,and hereby mtharim mprcalntatimsofthiscity mcnmrupnn the move-mentioned property for impcc0tn pugmses. W (We)agree to save,indemnify and kap harmkn the City of Cupertino against h Ilabilitin,ledgmems.costs and expenses which may in my only amus agumt We City ��vv ^in atmegame or the grandng Of this permh. Date a APPLICANT 7 UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: S SOURCEREGULATIO . i S'- Re-roofs Signature err Ap Xonumiar Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII the appliam an its=Wilding aceupmtwre a handle Meadows material As denned by tin Cupenino Municipal Cade.Chapter 9.12,and the Healm and Safety Cade.Section 25532(&)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes Pu Will the applicant or future Wilding anepant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants n defend by the Bay Area Air Quality Management all new materials for inspection. DlsWct7 Awt� ❑Yes lq!•u . I have mad the hnardnm materials requirements under Chapter 6.95 of Ne Gliror- me Health&Safely Code,Samoan 25505.25555 and 25534.1 tmdc tread Thu ifdn building deal tat cartn0y Mw mnmt,Nu It is my w"A ibility b tmtifY 0e mupnt of Nc mquiremenuwhkh be MCI imaWON tf Ocniaamoraaupaay. Signature of Applicant' Date Owaram ant Dain All roof coverings to be Class"B"or better Community Development a0l" 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 Fax(408) 777-3333 �UPERTINO Building De artment JOB ADDRESS: PERMIT# 2 6'o °7 OWNER'S NAME: I PHONE # 4 GENERAL CONTRACTOR 2421y2 1 FAX# 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 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 om 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35716068 . 00 DATE ISSUED. . . . . . . : 05/09/2006 RECEIPT #. . . . . . . . . : 34308 REFERENCE ID # . . . : 06050067 SITE ADDRESS . . . . . : 21915 LOMITA AVE SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : LUMIN CHANG ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : LUMIN CHANG CONTRACTOR . . . . . . . : GOUHONG LI LIC # 27796 COMPANY . . . . . . . . . . : LI ' S CONSTRUCTION ADDRESS . . . . . . . . . . : 654 8TH ST CITY/STATE/ZIP . . . : OAKLAND, CA 94607 TELEPHONE . . . . . . . . : (510) 261-8826 OEE 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 MASTERCARD TOTAL RECEIPT 100 .47 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL j CITE' OF CUP]ERTINO ,EMP SOWER ERT SCUP1NO PERMIT APPLICATION FORM APN# I ^^ h/�p� Date: lY INIU �-- p Building Address: ,9 l c'/5 dzou, a,-e Owner's Name: Phone #: L 3 -7 G CA e Contractor: L A C&--Qf-A"r),L Phone: License#: K (4 os ) rl -s G 3 CP 7 Contact: Phone: Cupetmo Business License#: Lur+ lAl a,4A^J h C1-4) 37 oC7 Q_ Building Permit Info: Elect ❑ Job Description: / 2 % I 1A2!4 Residentialf I�Y Coniniercial ❑ Cost of Project: • Qty. if Applicable Fee ID Fee Description Fee Group / BTEMP Temporary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING •