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03110027 (2) CITY OF CUPERTINO BUILDING DIVISION P✓RMl �+Q ..:11R1 �L+'l•''Agg��4I*N�TAO'n}+4"d ^a�'� ' '"+ BUILDING ADDRESS: RAY CHAN PERMIT N003110027 NCR'S NAME: _ 18615 LOREE AVE PERMIT ISSUE DATE RAY CHAN 11/05/2003 ONE: SANITARY NO, CONTROL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO • BLDG ELECT PLUMB MECH +00 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am licensed under previsions of Chapter 9(commencing p 6 with gcction]IXN)nr Divixion3 of NC Buaincxs and Professions Cetic.end myliccnu is j�? mfull forceand effect. WINDOWS & SIDING License Class Lick Dale Contractor SS ARCHITECTS DECLARATION W 1understand my planashall he used am public records 6 o in Licensed Pmfcssionel aS OWNER BUILDER DECLARATIONmeComeo y 1 natio affirm on 1 I.S.exempt Bmiar from Ne CommaC'a License r Law for Nc - <p o following reason. Panel t 71l]LBusincsa and vr.deinns Code:Any city er..c my m which requires n permit le tires the alley,improve,demolish, file repair any ned tarucmm $1400 t, triton its tensed crsuantalso gothe Po applicantswaOfor such Permit mliense Law(Chamem 2m (cat hereonan ingwiJPurstion7 h)ofDivionen oftheBuccemsancenselaw(C Code)or Sq. Ft.Floor Area Valuation that he is xempthhen,ien](X1 it Division r the .1 c,ad crearN n.Any lation or i�$ Net he u exempt therefrom and the basis for Ne alleged e¢mpaion.Any vinluinn of 37519004 . 00 Seelion 7031.5 by any applicant for a Permit subjects Ne applicant to a civil penalty of APN Number Occupancy Type not more Nan five hundred dollars(5500). P Y YP ❑La sownerof the property, re is cmntendea with wagesas Nei(Sole co ,Buss less will do the work,and Ne he Com is not intended or offereddo far nalc(Sec.]044,Business pandro Professional Code;The Contractor's License Lew docs not apply lf an owner of Required Inspections own property who$,Prods orimpmt suchves imprownand who does an hot eade oroffrer lhmugn his PiNt4LED ownemployee¢,provided Ihrdsuchentism ld wit arenot intendedmoRered formic.owner- however,the building or improvement la sold within one year of completion,to eof builder will have the burden of proving Nal he did not build or improve for purpose of male.).a NOV 1 9 2003 oX/as owner of the property,am exclusively contracting with licensed contractors m ectors came La the Project(See.to an Rosiness and ny wh i bur Code)The Cthrown. nd cense Law docs not apply m an owner of property who=d P M RnI E0proves Conlan,and, whence Lacts for such mjcaln withacentranor(s)liccnudpursuenuo Ne Conwnore BUILDING License Law. ❑tem exempt ec. - ,B&PCforrarc on net Data W KER'S COMPENSATION DECLARATION 1 ereby afs under Penalty of perjury me of the following declarations: 1 have and will maintain a Cenificr m of Consent no self-insom for Workers Duration- ..Lt..,as provided for by Section 3]00 of Ne labor Code,for on po fmmanca of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,ss required by Section 3700 or the Labor-Code,for lie Performance or the work for which this permil is issued. My Workers Compensation Immune carrier and Policy number mot: Canner. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This action need notbecemplcled If the permit is for one hundred dollars(SIM) or Ices.) 1 certify Nal In the performance of the work for which this Permit is issued.l shall not employ any person in any mannerm as to reams subject in the Workers'Compensation Laws of California,Dem Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to the Worker'a Compensation provisions of the Labor Code,you must = O forthwith comply with such provisions or this Permit shall be deemed revoked. z •"• CONSTRUCTION LENDING AGENCY H l he rebywhichrm Nalthereissued( econstructed.3W7,lending agency for performance of the work fur which lois permit is issued(Sec.309],Civ.C.) W Q Lender's Name z Under'¢Address O Q 1 certify Nat I have read this application and state that me above infmmniun is 1,, F correct I agree to comply with all city and county ordinances and mute laws relating to C U building construction,and hereby summirz represenadves or his city to order upon the 14 ahovo-mcntioned property for inspection purposes. gy (we)agree to save,indemnify and keep harmless the City or Cupertino against fq liabilities,judgments,casts and expenses which may in any way acme against said City fJ7 ineonuqueneeefm min flhia permit, r7 APPLICANT UN DS AND WILL COMPLY WI//A(.L%0�INT Issued by:%�(70 Date SOURCE REG - s. Re-roofs (D-3 ,Signal IicanU ommctor Datc '—/ ( / / A ARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building uccupa d store or handle havardous material u defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety Code,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed. ' ❑Yes �Ne win the.ppncanter"arum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove n hazardous air comominants as defined by the Bay Area Air Quality Management all new materials for inspection. trio? El Yes ❑No I have mad the havaNnus materials requirements under Chapter 6.95 of the Califor. ria Health tit Safety Codc,Sections 25505,25533 and 25534,1 undersand that it the building does not come Iy a wail that it is my responsibility r0 roti l'y the Occupant of Ne myutremcnts n. must be Ynct pdoneissuaneeorecenliencif0ecupan y. Signature of Applicant Date owner .ameri.ed a em Date All roof coverings to be Class "B"or better OTWER-BUILDER VERIFICATW 1. (Check one) I or my immediate family (parent,spouse or child) will perform: L A. All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(rev=7 � Property Owners Signature: Date: Job Address: gG �s �Y�z e E/,a Qa �/�/f Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. • • City of Cupertino Building Departm CITY OF 10300 Torre Aven C' I p C kT I N 0 Phone: (408)777-3226 Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself,you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family,and the work (including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding, federal social security taxes,workers' compensation insurance,disability insurance costs, and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your obligations under state law,contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino Printed on Recycled Paper ' s9Zx ami 1. F/ J1 sy�Xl w (Sl`r`tu� l L Ii 22 - / • s rr/rp, 7oi �1 APPROVED IN ACCORDING WITH)H GITY 01 CU?ERTti'O+CP E :)ATE ' l ~ >IGNEO_ — — k This s', '. pans and specifications / /v ' CID :. yt on the job at a l times and it is un lawful to make any changes or alterati.r.s on same MOW'-" w iUan perrr,ssion frorr. the building Cept., t'V Gf CUpe,tr^o fhe stamping of this pTae aad sped,rrztinrs SHALL NOT be he:d to permit o: fc be 8 krpproval of the violation of MYprovtsin� " ,r anv Cifv Ordinance or StEte :mow 'tll I � n r-r r `V NOV p. 5 2003 ----_ 15 WITY OF CUPERTINOO 2- CITY CITY OF PERMIT APPLICATION FORM 3 CUPEkTINO APN# 3-75 / IOD DD Date: Building Address: /g l� 1-dre-4— A✓e Owner's Name: U / Phone#: UM 7 3.3-9 Contractor: License#: Contact: Cupertino Business License#: Building Permit Info:, Bld Elect ❑ Plumb ❑ Mech ❑ Job Description: r Residential ❑ r ��915 e ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: 6 Occupancy oup .�7 Type of Cons ction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K 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/OfFComm/ uasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING � z37a � 1 of 3 /� C 4VITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BNINEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCONVAP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bidg Permit Fees BUILDING BPFLYTURE Pb1g Fixture PLUMBING BPGAS Gas Piping S stem Fee PLUMBING BPINI'ERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e 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 Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAMiAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> l OK 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 2 of 3 WITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT. Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmd] Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electricals foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot_^ _MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERNUTFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 30-v NOV 3 of 3