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05100220CITY OF CUPERTINO�'� 'Mc�4 a�s' .p * '�-= I. NF0RMAT1q BUILDING DIVISION PERNIIT CONjjU' gTOR ,• BULAINO ADCRESS: PERMITN0. 05100220 10170 STER14 AVE NAME: PERMIT ISSUE DATA ffR'S DAYWEN LI 10/27/2005 PHONE: SANITARY NO. CONTROL NO. ARCHrfECTIENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH l� LICENSED CONTRACTORS DECLARATION Job Description Job 1 hereby affirm that l m homed under pro W.M of Chapur 9 (Commencing with SecdN7R110) of Dividan 7 After Bum inand Professions Code,aad my license B kmnfanxAnd nit REPLACE MAIN SEWER LINE/30 FT OF PIPE neem°. Is.R Das r. CNusew 10/25/05 STAR ROOTER PD FOR BUS LIC A cxrTEcrs DECLARATION— 1 undern,ml my plans shall be used as public record, zw—, Licensed Professional OatNE. .pBR DECLARATION exempt from the Comrecss ticenm Law for the 1 heresy Affirm 1 axe 1. Alan. and Pm. all Cads: city or county following moon. (Saito 7(u 1.5, on Which requires aParrettr Cine, s. don pa ar -pan my Limum ud permit, healkcntI for such prior Wetimapions o for auehpermitsiceseiprdauumNt tho he u licensed pursuant s Om of es Loam haw (Clu 9 Ft. Floor Area a atia15000 Sq, O Y Code)u of Giv s Beef. ic) Saxien7000) of Oivmml ogtiro Budnm and nciae of use my pts on. vi Nat ha u exempt timrefrmn and the boo for the alleged amptioa MY viWNun of thathe Ale - Secdon 70713 by any applicant for a permit objects the applicant In a civil penalty of APN Number ccupancy Type not mom than five hundred dorm (SM. 3 % 512005. 0 0 01,uo roftlieprupeny,amyemploymwithwagesudu:irmk NmPcmdon, will do the work. and the auuctme is mtssnded aoRered fariak (SAC. 7044, Business and Profession Cade: M Conuseses License Law doe ret aPPly s N owner of RequireBIM Q property who builds aimproveatiureoaandwboduesarms wok him,elfor through his Am employs, provided thou such improvements m not Intended atffeled frcale. If. however, the Wilding As improvement Is sold within oro Year of eemPktion, the owver- Wilder will have the bodes of proving that he did ant Wild a Improve fa pulp. of 0 L as amer of the property, am emlusiwly contracting with licensed Nnuanon W constmcl the project (See. 7044. BYainm and Professions Code) The Countesses U. Nine law does not appy to an Amer apropenywho Wilds or improve tiwmoa, and, who Contracts for such projects with a contrectnr(s) licensed pun ant s the Contractees License Law. ❑Ire emptooder See .BlPC fa Nis rtum Das WORKERS COMPENSATION DECLARATION I hereby aOim under penalty of perjury one of the following decal Wats ❑ I haw And will maintain a CmNesm of Gonsens At self-InsumfaWarkeBCompon- sation, as provided for by $AWon 7700 of the Labor Code, for the pelftmNR of the work for which this permit is issued. ' ❑ 1 haw and will maintain Wakes Compensation Insurance, As required by Section 7700 ofthe labor Code, for the pArforomue Mthe ,it fawhlch this Permit u -51-d ' My Worker Ca Won Wersan er. W Policynumb, am: Cartier (f Policy No.: CERTIFl ATR OF EXEMPnON FRO WORKERS' COMPENSATION INSURANCE (Thu inion need not6ccompksd Bthe permit Is form hYnNnddoom ($100) ar lea) I anffy that in the performance or the wart for which this permit is issued I shall not employ my person in my man.,so As In become object or the Warlbuf CmponsedN Laws of California Date Ame cru t NOTICE TO APPLICANT: IL after making thio Conflicts of Exemption. you sous become subject m thc Workees Compensation provisions of the labor Coda you most forthwith comply with such provisions a this permit shall M dNmed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm We them Is a construction lending agency for the Performance of We was for whim this perch Is wood (Ss.. 7097, CW. C.) Undoes Name Lender's Address I I cenffy No I haw red W, Application and mm tho the above infomudon Is ' Como Lyme be comply With all city and county onlinaaes and sum lam relaxing to building nonsurtwoon, and hereby ausodre mptnenudves of this city to entcrupon the alcove -mentioned property for inspection purpaea (We) agree An ave, indemnify and Imcp hamlet the City of Cupertino agaWt j liabilities. judgments, cats and expense which may in my wayaaroe against said City in consequence of the granting of this Pamir APPLI UNDER Sf AND WILL COMPLY WITH ALL NON -POINT Issued by: Date 1p - 2 ? a--� d s _ U n0 . (" - Re -roofs n� Roof s' uce ranUConuacmr Data HAZARDOUS MATERIALS DISCLOSURE Type of Will the,Vpllmt or fumes building occupaalnon a handle hauNaus material deRmd by the Cupenfan Municipal Code, Chapter 9.17. and the Health Nd Safcly . Section 05572(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes 0 N If a roof is installed without first obtaining an inspection, I agree to remove Will We applicant a future building ocsvpam Am equipment or devise which emu hrrsdoa AirNnuminmu as dWncd by the Bay Ate Air Quality Mamecmcnl all new materials for inspection. owia7 OyAs ON. I hew real the Imanioesmaandaumquimaents under Chapmr6.95 of theCWfor. niAHeolthlS,felyCWUSccdm25505,55577and U534.lundcnundthaifihe building data nal cumntiY ve a snana sat It u my mponsUlllty m mtifY tiro aaupNl of Irk rnqul nor lost Prior arae karaapumy. Signature of Applicant Date All roof coverings to be Class "B" or better nnraraumoNrdagent Dam' I85n 1 of 1 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Elk: Lot: APN ........: 37512005.00 DATE ISSUED.......: 10/27/2005 RECEIPT #.........: 31764 REFERENCE ID # ...: 05100220 SITE ADDRESS .....: 10170 STERN AVE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: DAYWEN LI ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: suem COPY # : 2 METHOD OF PAYMENT AMOUNT ----------------- -----__----- CHECK 161.95 TOTAL RECEIPT 161.95 VOICE ID DESCRIPTION 106 SEWER & WATER 301 ROUGH PLUMBING 0 NUMBER ------------------ 1308 VOICE ID DESCRIPTION 202 UNDERFLOOR PLUMBING 507 FINAL PLUMBING RECEIVED FROM ....: STAR ROOTER PLUMBING CONTRACTOR .......: LIC # - COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... , TELEPHONE ........: FEE ID ---------- UNIT QUANTITY ----------------------- AMOUNT ---------- PD -TO -DT THIS REC NEW BAL BPSEWER SEWER SYSTEM 1.00 21.58 ---------- 0.00 ---------- 21.58 ---------- 0.00 BUSLIC FLAT RATE 1.00 102.00 0.00 102.00 0.00 PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 TOTAL PERMIT ---------- 161.95 ---------- 0.00 ---------- 161.95 ---------- 0.00 METHOD OF PAYMENT AMOUNT ----------------- -----__----- CHECK 161.95 TOTAL RECEIPT 161.95 VOICE ID DESCRIPTION 106 SEWER & WATER 301 ROUGH PLUMBING 0 NUMBER ------------------ 1308 VOICE ID DESCRIPTION 202 UNDERFLOOR PLUMBING 507 FINAL PLUMBING x Community Development 1 ' 10300 Torre Avenue ✓' Cupertino CA 95014 Telephone (408) 777-3228 . CITY OF Fax (408) 777-3333 SUPEkTINO Building Department I am not using any subcontractors: ` ' �ii) -,) 2'&f " Signature Date Please check applicable subcontractors and complete the following information: JOB ADDRESS: O /7D !�; > e- rtv PERMIT # ©- oo7-2d BUSINESS NAME OWNER'S NAME: P PHONE # 0 a 2 GENERAL CONTRACTOR: r4— PA ek'AX # I am not using any subcontractors: ` ' �ii) -,) 2'&f " Signature Date Please check applicable subcontractors and complete the following information: �i _/i �� --- . Contractor �Q ra Date 63 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glas§ /Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock all— I Tile �i _/i �� --- . Contractor �Q ra Date CC" •CITY of UPERTINO CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE PERMIT APPLICATION FORM &12 APN #Date: 3 s/ a e o6 5' BUILDING �o a7 -o s Building Address:zo/76 PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Owner's Na�5 ` / BPFIXTURE Phone #: S Or - Contractor: j / Phpne: r0� ©oTCt^/Z lUu �Ih (�,�� License #: S/7 Contact: ed hone: 377 ;F 7 Sewers Cupertino Business License #: Building Permit Info: `� z �j�GC t' rD.r �� ceRe 6L r o cc t t� � m p i ,p Q cid Cea/�e z Bldg ❑ Elect ❑ Plumb BUILDING Job Description: Residential Commercial ❑ Cost of Project: �T-,00v U Qty, if Anolicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS Gas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Repipe of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING r1 U