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03060097CITY OF CUPERTINO C^ QT0R"1 `FQAMATION � BUILDING DIVISION PERMIT CON ,R BUILDING ADDRESS: ASO N STELLiNQ RID QUANG VI HA 1110450 PERMIT NO. 03T0�60097 OWNER'S NAME: N STELLING RD' . PERMIf fscrg' 12/2003 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO ' BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION o lb Description mm mel I ren Emanated under provisions of Chapter 9 (coencing 1 hereby affirm nse with Section 7M)of Division 3 of the Business and Proksamu Code, and my license is ua(cl� ' react 7' FENCES pp�� �p p� o 0—'I9F1i ALE Ix.g Date Contractor ARCHITECTS DECLARATION I uMcrpaml my plana shall be used as public records JUN 2 7 2003 Licensed Profs usual OWNER-BUILDER DECLARATION 1 hereby affirm that I em exempt from the Contractor's License Law for IM BUILDING following mason. (Sudan 70315. Business and Professions Code: Any rimy or county which rox aims a permit m cmmamct, alae improve, demuluh. or repair my madam prior to its iuu.nce, alm required, the applicant rormch Permit to rile a signed satemcnt provisions of the Contractor's Llceaw(Chapter 9 that W is licensed p.... nuo Me, provisions La Sq. Ft. Floor Area $Y��ion (comencing with Section 71)(M) of Division 3 of time Business and Proressians CMR) or m that he R exempt therefrwn and the basis, for Em alleged exemption. My violation of 3ARFM N0tlw. 00 Occupancy Type Section 1031.5 by any applicull for a permit objects the applicant to a civil Penalty of not mom than five hundred dollars ($500). ❑ I,sswnerofthepmpmy,ormyemplo cswiLh gpsut irmlemmpenution, Ins ections will do the work and th ureCture is mainandad mofRred formal.(S.C. 7044, BWInCY and Pref ssiour Code: The Commuter License Law don ml apply to .n ow., of P eon, end who do.uch warkhimselforthrough his property who Wilda or improves mmu 102 - PIERS own employees, provided that such improvements me not mantled oroffemd f«ule. If, 103 — UFER however, the Wilding or improvement is sold within arc year of o mpletion. the owner. builder will have me burden of pouring that he did tot Wild or Improve for purpose of 104 - REBAR uu.)' 105 - ANCHOR BOLTS ❑ I. as owner of the property am exclusively contracting with licensed cantrecton to consnot to project (Sec. 7014, Business and Prefeulou Code:) The Contractors Li 10 6 — SEWER & WATER Certo Law dean ootimply to an owner of property who wilds or impmvcs theater. rand, 202 — UNDERFLOOR PLUMBING ' who ontracu for such pmjecu wire a eon0.mmis) licensed punum to me, nlr Coactoea License law. 203 - UNDERFLOOR MECHANICAL ❑ lamexemptunder Sec. ,B&PCfw EdsMmmr 204 - UNDERFLOOR FRAME OwD.� 205 - UNDERFLOOR INSULATION WOR O P TION DECLARATION I hereby attrm under penalty of perjury on, of ma followm tantions: 301 — ROUGH PLUMBING .'Bend willmeinuine CeNricsteof Consent tosel6Wsure for Workces Compcm 302 — TUB & OR SHOWER urian, u pouvidM for by Section 3700 of the labor Code. for the performance of the 3 03 — ROUGH MECHAN I CAL wait for which this Permit is issued. 304 . - ROUGH ELECTRICAL ❑ 1 have and will maintain Workees Compensation Instance, u required by Section 3700 of the Labor Cede, fm dte performance or mover, for which this Permit is issued. 305 — FRAME My Workces Compensation Insurance earriu and Policy number am: 306 — HOLDOWNS Carrie° Policy No.: CERTIFICATE of EXEMPTION FROM WORKERS' 307 - INSULATION COMPENSATION INSURANCE 308 - SHEETROCK (Thb motion need ml an complead it the permit la for one hundred dollars t$IW) 309 - EXTERIOR LATH culads) 310 - INTERIOR LATH I platy Nel in tow per(omanec of me work for which this Permit earned. I shall not emwtoyan veniny ymanncrmaztobewmembjecuotitowortteriCampens.Bon 311 — SCRATCH COAT Lawsofa is. DLte 313 - ROOF NAIL App h NonAPPLICANT: ILafaran.kingmuCeniOcaaofEacmPtion,yauNnulJ 501 - FINAL ELECTRICAL ENERGY bcc jot to the Worker's Compensation provisions of Iw Labor Code, you must faMwith comply with such provisions or this Permit shall he dcemed revoked. SO2 — FINAL PLUMBING ENERGY - CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY I hereby affirm that times In counclion lendinggency for the performance or 504 - FINAL BUILDING ENERGY the work fur which this Permit Is brood (Sce. 3097, Civ. C.) Landow Name 505 - FINAL ELECTRICAL - GAS TEST (� Lender'sAdd. I certify that I have read this application and now Nu to awrc information u 507 - FINAL PLUMBING trte Id comply With city and county ordinances and era fetaws relating to cacl. I agree re d (%!— building construction. and hereby aumarire representatives, of this city to enter upon the — FINJIL MEC ICAL . Wve-mcmdowd property ser inspeNnn purposes. FI (We) agree to an, indemnify and keep hamlets the City of Cupertino against liabilities, jadgmcnu. coats and expenses which may in my way accrue against sold city Al— NGto consequence of the grouting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5 C WORKSDate SOUR EREGULATIONS. Re-roofs Type of Roof i mrcof plical o Im HAZARDmaOUS MATERIALS DISCLOSURE Will the material or (Muni wilding occupant core or handle hualub a Oncd by the Cupertino Municipal Cade, Chapter 9.11. and lite Health and Safety a Cupertino Scum u531(a)a yyyy�fyy�''�''All ❑Yu �o jd,C. roofs shall be inspected prior to any roofing material being installed. a roof is installed without first obtaining an inspection, I agree to remove Will IAC aPP or fuwrc building use or whichIf onto by the B heurdnw air conuminanu u dc0ncd by 1)w Ray Amu Air Quality Maugcmcnt a Air Qu Mann all new materials for inspection. ic0 ❑Yea u Ilion real meheurdnua aterml. requirements umkr Chapter 6.95 ofthecaliror, nia Health & SafetyCodc, Sections 15505.15533 and 15534.1 undersuntl tharlrthe Wilding does not currently ban . tenant. that it is my (amenability to Imtify me pxupant OI the rcgeirementswhicharmsbe tpnnrtoustanuoraccniric I&eup,n . Signature of Applicant Date a� All roof coverings to be Class "B" or better nr autha lz1).sent Dote ./ 10Y Z 100 u 2 zzUU sda .�N rv�z CW, )yU C F ` LL C, yNa O..l <F i00p� SmW �Fa :)z z2 - (n CITY OF CUPERTINO BUILDING DIVISION PERMIT C4NT7RAGTOR INFCJRiV�AIU BUILDING ADDRESS: QUANG VI HA - PERMIT NO. 03060097 OwNER�S'AiME:" `"�"`•"�"`" 10450 N STELLING RD'. PERMIT ISSV712/2003 ARCHITECT/ENGINEER: LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of -Division 3 of the Business and Professions Code• and my license is In full fore a •(feet. License Lc. p Date t Contractor ARCHITECTS DECLARATION I understand my plans shall he used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improvc, demolish• or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (3500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work• and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thercon, and who does such work himself or through his own employees, provided that such improvements are not intended oroffered for sale. If, however, the building or improvement is sold within one year of cumpledon, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). [] I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 70". Business and Professions Code:) The Conuactoes Li- cense Law docs not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. ❑ I am exempt under Sec. . B & P C for this reason Ow cr Da r 12 WOR 'S COMPENSATION DECLARATION 1 hereby affirm under penally of perjury one of the following` eclaralions: C] I have and will maintain a Certificate of Consent to self -insure for WorkersCompen- sation, as provided for by Secdon 3700 of the Labor Code, for the performance of the work for which this permit is issued. C3 I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Polity number arc: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (3100) or less.) I certify that in the performance of the work for which this permit is issued. I shall not employ any` rson in a y manner so as to become subject to the Workers' Compensation Laws of Cali nia. tc Applic t NOTICIE,Y.0 APPLICANT: If, after making this Certificate of Exemption, you should bccoG~jccl to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ, C.) Lender's Name Lenders Address 1 certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building consuuction, and hereby authorize representatives of this city to enter upon the ahove-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. V HAZARDOUS MATERIALS DISCLOSURE 'i -- Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? - Yes 12]No Will the applicant or future building occupant use equipment or devices which emit hazardous air comaminanrs as defined by the Bay Area Air Quality Management District? C3 Ycs 4iHu I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health &SafotyCodc. Scc6ons25505,25533and 25534.1understand that ifthc building docs not cuaenily have a tenant, that it is my responsibility to nouly the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. agent Date SANITARY NO. BLDG Job Description 7' FENCES CONTROL NO. BUILDING PERMIT INFO ELECT PLUMB MECH Sq. Ft. Floor Area $ Mfjion 3ARNN �r 0 0 Occupancy Type &TikR[ Inspections 102 - PIERS 103 - UFER 104 - REBAR 105 - ANCHOR BOLTS 106 - SEWER & WATER 202 - UNDERFLOOR PLUMBING 203 - UNDERFLOOR MECHANICAL 204 - UNDERFLOOR FRAME 205 - UNDERFLOOR INSULATION 301 - ROUGH PLUMBING 302 - TUB & OR SHOWER 303 - ROUGH MECHANICAL 304 - ROUGH ELECTRICAL 305 - FRAME 306 - HOLDOWNS 307 - INSULATION 308 - SHEETROCK 309 - EXTERIOR LATH 310 - INTERIOR LATH 311 - SCRATCH COAT 313 - ROOF NAIL 501 - FINAL ELECTRICAL ENERGY 502 - FINAL PLUMBING ENERGY 503 - FINAL MECHANICAL ENERGY 504 - FINAL BUILDING ENERGY 505 - FINAL ELECTRICAL 506 - GAS TEST - 507 - FINAL PLUMBING i - FIN L MECAHANICAL 0 - FI - NG _W22 Issued by: 5 - C WORKSDate � Re -roofs Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better OWN tR-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: 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 erformed 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 (reverse (reverse side). n Property Ower's Signahu 1,14e-4,4 Z du Aate: Job Addiies,1 0,4( L2 �t # �7U t7 Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. CITY OF CUPERTINO Ci i Y OF CUPERTINO PERMIT APPLICATION FORM APN # Fee Description Fee Group Date: Building Address: MECHANICAL BBLDGFEE r ^U i _ Owner's Name: MECHANICAL BBOILER2 Phone #: , MECHANICAL BBOILER3 Boiler > 500K to 1 M Btu MECHANICAL Contractor: Boiler > 1M to 1.75 M Btu MECHANICAL License #: Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax Contact: 4 Ind/Off/Comm/Quasi Cupertino Business License#: B ing�Permit Info: Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING Blda), Elect ❑ Plumb ❑ Mech ❑ Job ription: Elec 600V <= 1000A ELECTRICAL ential ❑ Elec 600V > I OOOA Commercial ❑ Sq.Ft. Floor Area: Elec Svcs 600V <= 200A $/Sq.Ft.: Cost of Project: U Occupancy Group: BENERGYADD i BUILDING Type of Construction: Investigation fee BUILDING �� GL BUILDING �f Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1 M Btu MECHANICAL BBOILER4 Boiler > 1M to 1.75 M Btu MECHANICAL BBOILERS Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC 1001 Elec 600V > I OOOA 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 .c 1 of 3 aUCi I'Y OF CUPERTINO CITY°F PERMIT APPLICATION FORM CUPEI�JINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMTvfM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUM`LJLTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP 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 rinkler/Backflo 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 cfrn MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFCTRNOV 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 CITY OF CUPERTIN v CITY °F PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ED 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 Rmdl 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 Ins ection BUILDING BSWIM -Special Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3 of 3 � 1 7 n I f Ii { I l M ry 1 il o� Ez ELL Ex O E,., Gi cr a 2 x ui 0 1 H UNNI I' f i H Fj W o HnP . 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