06010133 CITY OF CUPERTINO
BUILDING DIVISION PERT <�Os\1RL�CTR'+IF dRMATION `:'
,+nY.ks>4,Gce6'
BUILDING ADDRESS: NICE & RIGHT CONSTRUCTION C' MIT NO'06010133
10111 SANTA CLARA AV
ERSNAME PERMIT ISSUE DATE
OWN
ZILLAH LIU 10663 SANTA LUCIA RD 01Z24/2006
NE: SANITARY NO. CONTROL N0.
(408) 861-0928 i
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
1Oz LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm Nat I am licemid under previsions of Chapter 9(commencing Job Description
with Section 70(a))of Division 3 of the Business and Professions Code.and my license is
IofmLfareeandeffect. Ba/�S6' TEMPORARY POWER POLE
ytg? Licenae Clav Lk.Y Ipt
ra Date r /ry Contracmr A&7_-A,Ci R1vT u�S7 ft ` �ne(IJ 111
�— ARCHm Crs DECLARATION —T C 2
i I understand my plans shall W used as public mcurda
I.0
yap r^ Licensed Profcssi...I 4i� no
g OWNER-BUILDER DECLARATION d Y
Y 1 hcrcby aITinn that 1 am exempt Imre the Contactors License Law for she
OO following mm.a.(Sac0on 21D 1.5,Bushmoijnd Prefc¢imts Calc:Any city or ommy fig
<S ff which mquirm a permit to construct,alter,improve,dcmnlish.or repair any,structure .,,,�, try V�ss� {� (�'.$t2 O O
°iy priomo itsissuanec,alsa requires the applicant forsuch permit refile a signed statement
<
that he is licensed p..stat1.ftprovisiomofthe Conuacmr'slittmseLaw(Chap¢r9 Sq. FL Floor Area Up LmId
Valuaiion
(Commencing with Section?000)of Division 3 oftW Businessand Professions Code)or
i $
that he is exempt therefrom and the basis for the alleged exemption.Any violation or
Section?031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dolim(5500). r_70 Occupancy Type
❑1,as owner of Ne property,or my employees wish wage,u their sal.compensation,
will do the work.and the structure is not intended oroRemd forsale(See.?OCA,Busium s
Rod Profash ore Cade:The Contractors Lianxe Law does trot apply in in owner of Required Inspections
Property who builds or imp rvia themon,and whodocsswitworkhimself orthrough his
own employees,provided that such improvements am not intended oroRemd forsale.If,
however,the building or improvement is sold within one year of completion,the owner
builder win have she burden of Proving this he did nos Wild or improve far puryose of
aate.).
❑I.as Owner of the,property,am exclusively contracting with licensed contracmrs to
construct the project(Sec.7044.Business and Professions Code:)Tbe Conbutoes Li.
came Law doom not apply in an owner of property who Wilds or improvoi thereon,and
who contract for such projects with a eanlretor(s)licensed pursuant to Ne Contra mar's
License Law,
❑I am exempt under Sec. ,B&P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under petalty of perjury arc of the following declarations:
1 have and will maintain a Certificate of Conant m self-insum for Worker's Comma-
.60 .u Provided far by Seed..3200 of the Isbor Code,for the perfarmaarce Of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Imuran,,u acquired by Section
3700 of the Labor COM,for Ne performams of the work for which this permit is issued.
My Workers
-CCostmpemation humor nim carrier and Policy number an:
/
Cartier,.S/lT� Jn/ Policy No.:OC2d//1—k'Op
C RTIFIC TEOFEXEMPlON FROM WORKERS'
COMPENSATION INSURANCE
(phis section need not becompleted Rthe pemnil is Foran,hundred dollars($100)
or less.
I certify that in the performance Of the work for which this Permit Is issued.I shall not
employ any person in any manner set as In become subject to M Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making Nis Certificate of Exemption.you should
become subject in the Worker's Compensation previsions or the Labor Code,you must
.J z forthwith comply with such provisions or this Permit shall W deemed revoked.
'Z'O CONSTRUCTION LENDING AGENCY
[-t I hcrcby-Mian that thea iso conmuninn landing.perry fm the Performance of
FL tW work fur which this permit is issued(Sec.3097,Civ.C.)
D] L.eadn's Name
D z Lenders Address
U Q I certify that I have mad this application and state that the above information is
U, F correct.I agree as comply with all city and county ordinances and state laws mlaung OR
0U Wilding construction.and hereby authome mpresematises of Nis city to enter upon the
r Ln ahov,-ms.judgedpfop ori(Rod expection purposes.
CL (We)ogre to use,indemnify and keep harmless M City of Cupertino against
N in
of UOcmBang expcnsmmit. may in anyway accrue against said City
U z A APPLICANT
of UO granting of this permit.
rpt APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
L
Signawrc of A>�VCon r Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tM applicant car future Wilding Occupant store or handle Iwardom material
as defined by the Cupertino Municipal Codi,Charter 9.12.and the Health and Safety
04ifict?
de,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �}t1u
/` If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which P g
it hazardous air contaminants m defined by the Bay Arta Air Quality Management all new materials for inspection.
❑Yes \ON.
I have mail New Nuusmawrials mquimmenr underCWpter6.95 ofthe Califor- -
hisHealth&Safety COM,Sccuaw 25505,M533 and 25534.1 understand thxlif the Wilding
does Out currently hate a tonna.that it is my amp newbility to notify the occupant of the
reyviremcnt.wnt m�Wmiapa;nrwissua �span_ ,y,. Signature of Applicant Date
ownero�ndage�, D�,te All roof coverings to be Class"B"or better
/a Community Development
,J
0 Torre Avenue
Clop rtinno CA 95014
5 ,..
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT#Q/ 0 /, '/�3
O C Q CSP ! C/
OWNER'S NAME: Z? 1G, IPHONE #
GENERAL CONTRACTOR: '- FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
63 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
er/Contractor Si ture Date
CITY OF CUPERTINO
TEMP POWER
CUPERTINO PERMIT APPLICATION FORM 0 01013-
APN # 3c� Date: D
Building Address: /
Owner's Name: Phone#:
Contractor: Phone: License #:
/v1C NS — — O Sc�
Contact: I f Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description:
Residential '� Commercial ❑
Cost of Project: p
Qoo u
•
Qty. if
A licable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING