08070181 CITY OF CUPERTINO '. a�*
BuaolNc ervlsloN . PERMIT yaCOP.ITRAGTzO- N, ORNIAT,ION„ .
BUILDING ADDRESS: PERMIT NO.
27.81.0 MERCEDES RD TBD — TO BE DETERMINED 08070181
OWNER'S NAME: PERMIT ISSUE DATE
CHI: NGUYEN 07/25/2008
10 NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
TEMP POWER POLE. SPECTRUM O O PLUMB
MECH
0
Z o p LICENSED CONTRACTOR'S DECLARATION -
u I hereby arum that I an Retreated ander provision,of chapter 9(...in, ..__ ., „. „„ Job Description
- `ef HthSectim]IXIU)of Dmtilmlof the ButinaaaM Prafestiam Cme.aM mYlu.mi,
in full fora and cffe m 8 2 Z Z
j�Z Licen¢CIuf 1 3 Lu.g —
�a Dau 21 MaK 1, OConlmar U e eN TMAicir, O rJ
ARCHITECTS DECLARATION
I understand my plane shill W used u public accords
3yV
It G Lkcnwd Professional
OWNER-BUILDER DECLARATION
T hereby affirm that 1 am exempt from the Conuaclo's Licenu law for Ne
y
00 following rcuon.(Section 7071.3.Busincu and Proludou Code:My city of aunty
rd$V which acquire a permit an cenmucL alter,impmw,demoluh,or repair any muctum
zy prim b i4 iatutume.also requirta the applicant formch parfait in file a signed immumnt
S< d W is ficermodpoommattothe,provisions ofthe Contractor's Licereen Law(ChiplR9 Sq.Ft. Floor Area Valuation
yFg (commencing with Section 70001 of Division 3 of the Busimer and Profcasiwta Cade)or
— leve W u exempt Nuefmen and the bust for Ne alleged cnmptim.My violation of
Sadon 70313 by any applicant fa a permit abjaas de appluant in a civil penalty of APN Number Occu ane e
m1 moa than BK handmd 03 P doll.(150Y�'P
❑1.-owneroftle property,or my emPloyeu with wage u 0mehule compeneatim,
will do the work.and mho structure unotimended or offered forasu(Sec.7014,Bu,ineu
Coder Th
and Forked..Code Conoacme,LI.Lawoe,na
dl apply m an awn.of Required Inspections
property who builds Or impmveuhmon,and who does such wort himself or through but
own employes,provided that such impmvemau are not intended oro@acd formic.IL
however,the building or impmvemenl is sold within ane year of completion,the owner.
builder will Nae dere burderm of pmmg the K did not build in improve far Potomac of
talc.).
❑1,u owner of the property.am ucludvely contracting with Ewued com acars at
couuuct IK pmject(Sec 7llbd.Busimss ab Pmfessiom Code:)The Cmczca s U.
coax Law dost col apply In an owner of property who Wilda or Improwa domino.and.
what,mnoacts fwsueh pmjccu with•comm on,)liaised puravanl in the Cmuawor"
I-=L.W.
Imommmpundm Sec. ,B&PCfarthisacuon _
Ow w �N
WORKER'S OMPENSA RA
1 hereby affirm under acuity of perjury me of the following declwiam:
ban,and will maintain a CeeiEMM of Comeau Self-inure fa WOM1eng Campion- -
ire.u provided for by Section PW of tha labor Code.for the performance of the
work for which this permit is issued.
❑1 haw and will remain Worlou s Comprnut iuwut¢,u requfed by Seeder
3700 M the labor,Cade,for the pedarion.of the work fa which au permit u/ssue6
My WarteYs Compemuim hsmran¢artier and Polity number we:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thu xnim ancd mtb emmplcudifte permit is fwone hundred dollen(3100)
or leu)
1 anify Nat in the perform ee of the work for which this permit is issued.I shall not
cmploymy permn in any mumrappbb� subjatu One Workcn'Compcuatian
Taws of California.Data 0/9-S7s�-7C
Applicant
NOTICE TO APPLICAN F IL aper madding—this provisions
a of Exemption,,y thaua
.,Qb.ome comp y the Woheam Co ma or thia pmvisi ai of the Labor.Code,vest must
foMwith comply with team povuiou w Nu permit shill W drenied matrQ
E+�" CONSTRUCTION LENDING AGENCY
Ithereby arfirm mho dem is.comarmden lerkingagcm,for dmp Konammoof
C > the wart for which this pmmit i,issad(sec.3097.Civ.C.)
Lender's Namc
ru7Lcndeh Mdacu
U O 1 anify that I have mad this application and mute d u the above imdwmado.u
U. F coraco 1 agme a comply with all city and county ordlrwmea and sou Ian relining te
OU Wilding constmction.andhemby mthodm mpmuntatiwsofthu city memerupnn the
above-mentionW property for iospee0un PurpamL
H 4 (We)agree to caw.indemnify and lump humleu tW City of Cupenme,toned
ti to liabilities,jougmenu.coon,and expcues which may in any way.against mid City
U z in comequeree of the gfanting of this permit.
'--' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date L _
SOURCE REGULATIONS.
71ZS/ZOO Re-roofs /A
smgwme mnppheanNCamwner Mme
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W10 the applicant w future building—Part tore mbandle hauNou material
u defined by the Cupenim Municipal Code.Chapter 9.13,aM the Hcalth and Safety
Code.S:]Y.zss3z(,)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya ,y�rva
Will the applicanu ar futuac building occupant use equipment or daM=which If a roof is installed without first obtaining an inspection,I agree to remove
mho Nna ter cmumiwm//u u dcfimd by the Bay Area Air Quality Marm,tum t all new materials for inspection.
❑Yu �No
I low read the harearc reamrid,acquhemenu undcrChapeer 6.93 of the Cidifor.
out Health&Satiety Cade,Section 25703.25533 and MIX 1 un icamand the ifde Witching
deo Out curtcndY hew a amam,Nat It is my mapmed bility in notify de wcuyanl or de
acqumme tawbich utbc met prior to ismawe of a C.ureste or jSL Signature of Applicant Date
� Q
Owner or authon>sd agent Dame All roof coverings to be Class'%¢"or better
CITY OF CUPERTINO
. 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . : . . : 34222106 . 00
DATE ISSUED. . . . . . . : 07/25/2008 -
RECEIPT # . . . . . . . . . : BS000005589
REFERENCE ID # . . . : 08070181
SITE ADDRESS . . . . . : 22810 MERCEDES RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHI NGUYEN
ADDRESS . . . . . . . . . . : 22810 MERCEDES RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CHI NGUYEN
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . ..
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
---------- -- --------- ---------- ---------- ---------- ----------
IBSEISMICR VALUATION 70, 000 . 00 7 . 00 0 . 00 7 . 00 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1ERT<200 UNITS 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
ITRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 129 . 37 0 . 00 129 . 37 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 129 . 37 AMERICAN EXPRESS
---------------
TOTAL RECEIPT 129 . 37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
•
0�076is
CITY OF CUPERTINO
TEMP POWER
CU TY TING PERMIT APPLICATION FORM
APN # � Date: 7/zs�Zo o �
Building Address:
2-2 8'1 0 AA &ZC— PES RoAI_
CJPERTiNo G SOS
Owner's Name: I
Phone #:
CHi rv�, vYErJ (yok) 83 '� - 6c-
Contractor: Pl ccG �ia Phone #:
Contact: Phone #:
Contractor License #: (097 1,(n 0
Cupertino Business License #: .
Job Description:
T16MP 1'o rER �' ot_ E
Residential 2� Commercial ❑
Valuation (cost of project):
r � SO o
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>1K Res. Temp Power>IK E 1REAP14
Am2s
/ 1 ERT<200 Res. Temp Power<200 E
Amps
1 ERT2001 K Res. Temp Power 200-1 K E
Amps
MA 1 EPERMITFE Electric Permit Issuance E
IELCPLNCK Electric Plan Check E
1BSEISMICR Seismic Residential g
1TRAVDOC Travel & Documentation B
Fee
CITY OF CUPERTINO
;h TEMP POWER
CITY OF
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description } Fee Group Permit Type
1BSEISMICO Seismic Commercial B 10EAP,14
IECT<200 Commercial Temp Power E
<200 Amps
IECT>IK Commercial Temp Power E
>1K Am s
IECT2001K Commercial Temp Power E
100-1 K Amps
1TRAVD0C Travel & Documentation B
Fee
1BUSLIC Business License B
s
Community Development
10300 Torre Avenue
s Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
*UPERTINO
Building De artment
JOB ADDRESS: PERMIT# ofQ/�/
22810 ME(ZC-EDCS ISD cUP�r2Tl�to 6.0,95-°
OWNER'S NAME: L V PHONE # qo8 8 G
GENERAL CONTRACTO • Co n4S'rr?4 G-T1 a FAX #
sora Z��43�^
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
G' 712 Lf /z o o
Owner/Contractor Signature Date