06060075 CITY OF CUPERTINO - 3i. c
BUILDING DIVISION PERMIT '„ ON;TRA.GtI'C}R'INF,O ,TIQNN ;
BUILDING ADDRESS: LI ' S CONSTRUCTION PERMITN0.0 6 0 6 0 0 7 5
21915 LOMITA AVE
OWNER'S NAME: PERMIT ISSUE DATE
LUMIN CHANG 654 8TH ST 06/09/2006
,Et SANITARY N0, CONTROL NO.
(510) 261-8826
ARCHITECTAENGINEER: BUILDING PERMIT INFO
BLDQO O PLUMB MECHO
loo LICENSED CONTRACTOR'S DECLARATION Job Description I haroby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
with Section 70U)of Division 3 of the Business;and Professions Code,and my license is
in full faroeandeR«I. ADDING NEW GASLINE TO SUPPLY EXSISTING DETACHED
i Z Lica se Clue Lie.0
I-p Dcomusaar GUEST HOUSE
Dan
I ARCHITECT'S DECLARATION
j I undenund my plans shall be used as public records "I c L"I'D
'u Licensed Professional
•N OWNER-BUILDER DECLARATION
1<z 1 bercby air.that 1 as exempt Amro the Conoaaofs License Law for the
s O O fallowing mean.(Section 1031.5.Busimas ad Professions Cade:Any city or county
which requires a permit m constants.NEW.Wpove,demolish,or mpau my avucture
-ZN
prior It,its notation.WU requir61Le applleml for such Permit an Ble!signed alalelnaa 2006
F that ha u licensedportant to the provisions of the Comra on's License law(Chapter 9 Sq.Ft.Floor Area Valua[i$IS 0 0 0
1^� (Commencing with Section 7000)err Division 3 of dm Business ad PmfGalaM Cattle)or
that ha is eumpt Iben•.(rom ad the bub for the alleged eamptim.Any violation of
Seton 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of ppb Number ccupancy Type
trot mom the Ove hundred dollars(5500). 3 5 716068 . '0 URU
❑1,a wmer of the Property,err my employes with WSW as their Ile co spec atiaa•
will do Na work and thasbuaum In not intended eraRercd forsao(Sec.TOM.Business Required Inspections
ad Pmfeaions Cade:The Comm odes License law does at apply m e a owner of q p
propertywho build,aimproves d ndon,ad whodoessuch workhimselfor through his
own employees,provided thatamh Improvements art nothanded confkrod f reale.If.
however,the building or Improvement I,mid within orc you of completion.the owner-
Wilder will have the burden of proving that he did rot btik m Improve for purpose or
ae,J.
I.u Water of the property am conclusively carousing with Ocanst contractors m
comtmct the project(Sec.7044.Businea aha Prokadons Cade:)The Conmeutrs Li.
cense law dos not apply on a owner of property who W IWs or improves Demon,ad
whom
comment fat such projects with a eonnm(a)alIkenad pursuant to Bre communes
Llem.law.
❑lrum mospt under tee ,B At P C fm'this mason,
Owner �� Date
9 COMPENSATION LARAT30N
1 hereby LMm miler penalty of perjuryam of the following dl l mdam:
I ham sed will maintain aCarti car of Conant to alf-in um
tfor Wmint',Cempen-
son,a provided fer by Section 3700 of rte labor Cade,for the pmlco erfaof the
work for which this pmeh b Issued. _
Q 1 have ad will maintain Worker's Compensation Insurance,u regdired by Section
3700 of the Labor Code,for the perfomanee of the wart for which this permit Is issued. '
My Workmen Compensation Insurance artier ad Policy number are:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rrhbscNcan need at be completed Bthe permit is foram hundrtddo0an($100)
or less.)
1 artily that In the performance of the work for which this permit is fated.I Ideal cot
employ any person lnmy macer! sub: abject Ed WorkctYCompena0m
Iof cahromla.Dam 9.�` �., (o
Applicaa
NOTICE TO APPLI NT.It..after mating this CmdI1cAsW Exemption.you should
become subject b the Woftes Compensation provisions of tha labor Coda you moa
O faMwith comply wit such provisions or this Permit shill W dencmt revoked.
z"" CONSTRUCTION LENDING AGENCY
l hereby affirm the than:iso moment.lending agency ter the perm ce.,tr
C ti dx wart fm which this permit In unu !(Sec 3097,Civ.C.)
4 Q La rices tax '
]Z Lendmes Address
U0 I certify that 1 have read this application ad sate that Ne show Informatiun is
U,Pcomet.I agree to comply wit all city ad county ordinances and sou Ems relating m
U building construction.and hereby authome represonutives of this city to enter upon the
�4a7 above-mentioned property for inspection purposes.
O. (We)agree maw,indemnify ad kap hanky the City of Cupenino against
r/1 liabilities.Judgments.sew ad espenxa which may in my way acme against aid City / fs �f
U,'Z in consequence of the granting of this permit. / /'1.,r/�
^� APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date {( E U""
SOURCE REG�IU ATA�`��� Ge- U,6
Signatures AppllcmUCanuxmr f� Dat Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dx applicant Or future Wilding occupant nae or handle,hamduo manurial
as defined by Ne Cuperum Municipal Code.Chapter 9.11•ad the Health and Safety
Code,Seton 25532(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes a
Will the t err future building a.pat am equipment er de lea which
a roof is installed without first obtaining an inspection,I agree to remove
mit hu rad..air conumisunu a de0md by due Bay Area Air Quality Maagemenl all new materials for inspection.
DiI0ia1
❑Yen
1 have mad the havardma maxriab requirements umler Chapterii.95ofthe Califor.
nIa HmlN,SirctyCod.,Soni..25505,25533ad25534.1.d..Wd Nalfdx Wilding
doesnot cumntly ha tenal that It Is my responsibility m notify the aauient of dx
mquhaments whk b,cot prior tu usecnce of a Cmfikate or occopaxy. Signature of Applicant Date
Owner a N m a cnt Dow All roof coverings to be Class "B"Or better
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . : 35716068 . 00
DATE ISSUED. . . . . . . : 06/09/2006
RECEIPT # . . . . . . . . . : 34780
REFERENCE ID # . . . : 06060075
SITE ADDRESS . . . . . : 21915 LOMITA AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LUMIN CHANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
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
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPGAS OULETS 1 . 00 5 .40 0 . 00 5 . 40 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 43 . 77 0 . 00 43 . 77 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -------- ----------
OTHER 43 . 77 VISA
TOTAL RECEIPT 43 . 77
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
aClOF Fax(408)777-3333
WUPEkTINO
`k Building Department=
JOB ADDRESS: PERMIT#
z(`?ts D666a6 '�s
OWNER'S NAME: ,y, �.� , ,� PHONE # zL c,eF -3 93-V 6 U
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:�>.t�:- �— �_ G ' Fa
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
y
Owner/Contractor Signature Date
CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE
•CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
6 - I _ u
Building Address:
z e,�. 9�i
Owner's Name: Phone#:
Contractor: Phone: License#:
. c a & d-
Contact: Phone: Cupertino Business License #:
W -3 c?
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Ll
Job Description: 7 �I RX
Residential Commercial ❑
Cost of Project:
• (f V
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•