08040069CITY OF CUPERTINO T�a,Yi
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BUILDING DIVISI(W PERMIT
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BUILDING 4DRESS:
PERMrr NO.
1021 PASADENA AVE LOT 1
NATIONAL CONSTRUCTION
08040069
OWNER'S NAME:
FERhBT ISSUE DATE
JYAN-PING LILY CHANG
15319 CHATSWORTH ST
04/09/2008
PHONE:
SANITARY NO. CONTROL NO.
(818)221-6057
na
CHITECT/ENGINEER:
BU ILDINO PERMIT INFO
BLDGE_ PLUMBO MECH
O O
LICENSED CONTRACTOR'S DECLARATION
Description
I home, Milian that I am licensed under provisions of Chapter 9 (mmmeaing
.lob
with Section 7") ol'Divislon 3 of the Business amd Profession, Code, am my license is
TEMP POWER POLE
In full roma and affect.
Ucem m Class Lis. a♦
.
Dam Contractor
ARCHI7EC'S DECLARATION
I understand my purrs "I be need u public mcmeds
Licensed Pmfcssiomd
OWNER.BUILDER DECLARATION
I humor affirm that I am eiempl from the Contractor's Users: Law for the
following mason. (Section 7031.5. Business and Professions CO& Any city or c'ounly
Which requires a permit to ennwak alter, improve, demolish, or repair any someone
prior to its issuance. alma bequims the applicant for such permit be Ole a signed Batement
that bo is licensed to the of the ConoaeMel License Law (ChaPW9
Sq. Ft. Floor Area
Valuation
pursuant pmviSMAS
(commencing with Section 700() of Division 3 of the Business and Professions Code) or
$1000
that rte is exempt therefrom and the basis for fm alleged exemption. Any violation of
Number
- Occupancy Type
Section 7031.5 by any applicant for a Permit Ideeeu On wpikant m a Civil Pmalty of
ro
Act Mae than five hundred dollars 5500).
3 5 717 0 45 (
❑ I. u de prnpctty, a my wployes wW mages u tkkwk cmdpetmness
Required Inspections
Anti dothemart antlthe oh Act adeds for Toad, Business
true .,it.
a. do an, applfsAy
And! Code The Cwtncton, T.imtee !Ave does an apply te rt ower of
propertylobobobIda ireprovesfh And wbo amenouchmark kisser!rmeIhroe{6 his
cnywhoW
impr moHeeed for own er,
awe employes, presided that wen impmsemw
i see not
ofW
midwithinaneyea of c
t year
brweronin for deeower
thturimpmwnvinis
prove
builder NO Nw Na bmdrn of proving WI k did rot build a improve far Wmoee of
have
ask.).
&I. as Owner of Na property, am esGmively contracting whit licensed contrantan as
comtiutt the proiun (Be, 7004, Business and Professions Cade:) The Conmemes U.
nes law dose nut apply an an Or of property who Wilda or Improves tlteman, mad,
macufonuch jecu wiNaeonuumr(G licensed Parma.. be Ne Contractor's
Law.B
& P C far dfaDateWORKIR
CO PENSATION DECLARATION
;for
1 bya1Mo under pcullY o! perjury arc of fe (olWwinl dalaruioneove
aud will maintain a Canifiestearcamsenl be eelyiuum fe Worker'sCompor-
. u providM for by Section 3700 of de Labor Code. for the performance of the
which Nis permit m bound.
❑ 1 have and will maintain Worknes Compensation Wunnce, u tequimd by Section
3700 mf Ne labor Code, for the performance of the work for which this permit is issued.
'
My Worker', Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS
COMPENSATION INSURANCE
rlTk=am aud not W compimed new pemil is fame hoodlM denan (SIM)
or less)
I anify tort in the Per... Of the wart for which this permit is issued. I shill ma
my
any person in any maam�etam y subject m the Woken'Canpwa m
Lawsemployo Vbccmno
Laws of Daus 1 fu
Applicant
-
NDnCbeton. U B, after mWnsn this ME
Exemption, you. ouki
atmr
becane robins m Ire Wakcr'o Compensation provision of dm labs Cane M.
Mum.af mut
_
' fanhwiN comply MIN wen provisions a this permit. shall bo lamed mwked. .
I
'
CONSTRUCTION LENDING AGENCY
I hereby aaim Nu Nem is a cunwatinn Iending agency fords rmfamanme of
the wrk for which this permit Is fumed (see 3097. Civ. Cd
jLender's Name
lenders Address
I i cenify that 1 have mW its. Application and m c Nu tle above information is
'
' correct. 1 agree to comply with W city and county on inucra and state law missing N
Wilding couuuction, and hereby uWonse representatives of this city in cnw upon Ne
1 +hove-mentioned propel fes uapcctian Purposes
(We) ogtee in eve. indemnify And kxp harmlem ole City of Cupertino ,Saint
j liabilities. judgments. cons and expense which may In may try menus agalul said City
I. <otmqutnee m Nm noting of Nis permit.
O
APPLIC NT U STANDS AND WILL COMPLY WITH A11. NO NPOINI'
Issued by: Dale
SOUR TIONS.
Re-roofs
Type of Roof
w"
Sign moa t/COnummor Data
RDOUS MATERIALS DISCLOSURE
WIII the applicuet a factum building ocwPantoore a lural. huaNau material
u deRaA by the Cupertino Mwdcipal Code. Chapter 9.12, mad the Health and Safely
Cole, Section 25532(x)?
❑Yes Na
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,agree to remove
Will Ne applican, or future Wilding acopanl use equipment or dcvlaa which
.I
t hu inu u defined by Ibe Bay Ama Air Quality Management
ardw nAir conumw
all new materials for inspection.
ct7
❑YCa
hasallou/ mamrialseequmems under Chapter 6.95 6.95 ofCanfw.
I have mad theim
w Health&S mf Cade es25505,25533uW25534.1urkg WNa iflhddldkg
fan not more try hero a t. Nat it k my responsibility N ratify Ne occupant or de
mquimmen hie mel prior to iawmca of a Cenifiran oftkcupwey.
Signature ofApplicant Date
g
Y
All roof coverings to be Class'W' or better
Date - -
Ow arwtharivcdagcmt
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT
Ser. Twp: Rng: Sub: Blk: Lot:
APN ........: 35717045.00
DATE ISSUED.......: 04/09/2008
RECEIPT #.........: BS000004428
REFERENCE ID # ...: 08040069
SITE ADDRESS .....: 10121 PASADENA AVE LOT 1
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: JYAN-PING LILY CHANG
ADDRESS ..........: P 0 BOX 33097
CITY/STATE/ZIP ...: LOS GATOS, CA 95031
OPERATOR: patg
COPY # : 1
RECEIVED FROM ....: JOSEPHINE Y CHANG
CONTRACTOR .......: NATIONAL CONSTRUCTION RENTALS LIC # 22537
COMPANY .:........ : NATIONAL CONSTRUCTION RENTALS
ADDRESS ..........: 15319 CHATSWORTH ST
CITY/STATE/ZIP ...: MISSION HILLS, CA 91345
TELEPHONE ........: (818)221-6057
•FEE ID
UNIT-----
QUANTITY
.AMOUNT --
PD -TO -DT
THIS REC
NEW BAL
----------
1BSEISMICR
--------
VALUATION
----------
1,000.00
-------=---
0.50
----------
0.00
----------
0.50
----------
0.00
1EPERMITFE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
IERT<200
UNITS
1.00
40.79
0.00
40.79
0.00
1TRAVDOC
FLAT RATE
1.00
40.79
0.00
40.79
0.00
TOTAL PERMIT
----------
122.87
----------
0.00
----------
122.87
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT
AMOUNT
---------122.87
---------122.87
VOICE ID DESCRIPTION
-------- ----------------------------
402 TEMPORARY POWER
r
U
REFERENCE NUMBER
------------------
VISA
VOICE ID DESCRIPTION
-------- ----------------------------
CITY OF CUPERTINO
TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
0
o�vypobq
APN #
k;5r 7(D
v
Date:
Fee Group
Permit Type
Building Address:
Res. Temp Power >1K
E
Owner's Name:
Phone #:
Amps
Contractor:
IERT<200
Phone #:
E
Amps
Fax
Contact:
Phone #:
Res. Temp Power 200-1K
E
Contractor License #: (p S� 1 to p
Cupertino Business License #:
\ o D g
Job Description: .
/
IEPERMITFE
Electric Permit Issuance
Residential
Commercial ❑.
Valuation (cost of project):
1ELCPLNCK
r
L
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IERT>lK
Res. Temp Power >1K
E
1REAP14
Amps
IERT<200
Res. Temp Power <200
E
Amps
IERT2001K
Res. Temp Power 200-1K
E
Amps
/
IEPERMITFE
Electric Permit Issuance
E
1ELCPLNCK
Electric Plan Check
E
/
1BSEISMICR
Seismic Residential
B
CITY OF CUPERTINO
TEMP POWER
CUPEI,TINO PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IBSEISMICO
Seismic Commercial
B
10EAP14
IECT<200
Commercial. Temp Power
<200 Amps
E
1 ECT>I K
Commercial Temp Power
>1KAm s
E
IECT2001K
Commercial Temp Power
100-1K Amps
E
lTRAVDOC
Travel & Documentation
Fee
B
1BUSLIC
Business License
B
1-1 L
0
CITY OF
`UPEkTINO
Cj
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
0
PERMIT #
0�-,,00 6
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR: Q�� c
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Co tractor Signature
a
ate
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
Til
Co tractor Signature
a
ate