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03050037 crrY or curraT[lvo BUILDING DIVISION PERMIT TOWINFORMATION51. BUILDING ADDRESS: PERMIT NO„3 0 5 0 0 3 7 FITS NAME: PERMIT ISSUE DATE P ONE: SANITARYNO. 2 CONTROL NO. ARCHITECryENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O O O O ±op LICENSED CONTRACTOR'S DECLARATION �miE 1 hereby affirm that 1 am nceosed under provisions of chapter 9 moe menemg Job Description �s1�� <G wiN Section Rgl(pof Division 3of NC Business and Professions Code,and my liccnx is ��® < in full force and effect. 1gjE License Class Lic.0 TENANT IMPROVEMENT - eaE� Date Contractor DEC gg 2003 EC 1 a7 ARCHITECTS DECLARATION - L C i U 1 understand my PIam.Call be uxd as public rtenNs `o1 LicensedPndcssional �' �'�� �1 5 OWNER-BUILDER DECLARATION ■`D 20 0 1 hereby affirm on 1 am exempt from Nro Csecons o Any c Law rut Nc p O which followingMason.Permian 703L3.Business and Profession Code:Any city of country $ whim requires n permit to construct.the almh improve,demolh remarked or repair any statement thathe its issuance.Clsurequires thcaiionso(the Con Petor's fiensele a Lnedetammem F (Commisedpunuamh0k))o(the visionofortheBdinessandProd ssunChapwr9ode)or Sy. Ft. Floor Area Valuation ++ (Commencingheisxempth Section70k))and o(Division do, Business pion.Any Violation or Na(he ts exempt Ncmfmm and Ne basis for Ne alleged exemption.Any violation of 31621090 . 00 Section 1031.5 byby applicant for a pc.it,.bj,,u the applicant to a civil penalty of APNNumber Occupancy no(more Nan five hundred doll...n!R)0). pane y Type ❑1.as owner of the fropeny,or my employees with wage,u Neir sale emopenadon, will do the work,and the suvaure is not intended or offered for Sete(Sec.7044,Holiness and Professions Code:The Contractor's License law dolt ons apply in an owner of 102 - PIERS d Inspections property who builds or improve,Nescreon,and who dosuch work himselfm through his Own employees,provided chat uch improvements are not intended oroffered for sale.If. 103 — UFER however,the building or improvement is sold within one year of completion,Ne ownerry builder will have the burden of proving Na(he did not build of improve for purpose of 104 - REBAR sail.' 105 - ANCHOR BOLTS conns,a nwncr fl ct pro.704f+m exclusively mesand contracting wild licensed contractors i. construct the pmjen(Sec.]IN4,Bu.iness and Profession Code:)The Conmeari u. 10 — SEWER & WATER cense law does not apply to an owner or property who wilds or improves demon,and, 202 — UNDERFLOOR PLUMBING whocondacufor,uchprojecu withac d .,(I)licensed pumuem to the Contractor, License Law. 203 - UNDERFLOOR MECHANICAL ❑tem eaemp(unde ,B&PCfn Ni mason 204 - UNDERFLOOR FRAME ION 0 205 - UNDERFLOOR INSULATION WORKE ' �1PENYt P OEC ATION trmunder penalty of pejury one of the following declsfoions; 301 — ROUGH PLUMBING ❑I have and will maintain a Ccnificate of Consent m self-usure for Wortrr's Comfort. 302 — TUB & OR SHOWER ration,as provided for by section 3]00 of the labor Code,for the performance of(he 303 - ROUGH MECHANICAL work for which this fermi(I.issued. ❑I have and will maintain Worker's Compensation Insurance,n required by section 304 - ROUGH ELECTRICAL 7]W ofthe labor Code,for Ne performance of the work for which this permit is issued. 305 — FRAME My Workers Compensation Insurance carrier and Policy number am:Policy NO.: 306 — HOEDOWNS Carrier, CERTIFICATE OFEXEMPIONFROM WORKERS' 307 - INSULATION COMPENSATION INSURANCE 308 - SHEETROCK or ossa.This section nem notes completed vibe rcrdis is for one hundred dolars(HINE 309 — EXTERIOR LATH I Caniry that in the performance of too work for which Nis Permit is issued,l man not 310 — INTERIOR LATH employ any person in any manner m m to become subject o the Worked Cnmpenaion 311 — SCRATCH COAT Lawsca California.Data Applicant _ 313 - ROOF NAIL Law. NOTICE TO APPLICANT:If.alter making this CCN(Ieate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY become Comply the women Compensation permit hal of DO,LaborfCore.you nun 502 - FINAL PLUMBING ENERGY �,2 become object wits such er'sCmensatinpermil shallbedccm boli COE, ?C CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY I hereby affirm that there is a conmuc(inn lending agency for the Performance of 504 - FINAL BUILDING ENERGY zCI thework101 nthis p mit i.ia d(srd5091.civ.ca 505 - FINAL ELECTRICAL JJ Q LenderssName �z Lender's A°°� 506 - GAS TEST j 0 1 merry that 1 have read this application and stoic that the above information it 5 0 7 - FINAL PLUMBING y comet.1 agree to comply with all city and county ordinances and state laws relating to 7V building conweion,and hereby authmire mprommebms or this city to enter upon the FIN MECHA(NG' L 1 anave-mentioned property for inspection purpoms. ti (We)+gree m save,indemnify and keep handless the City of Cupcnino egaims O 9 FI �! h liabilities,judgmcna,costs an ich may in any way acc=against said City J in comm to of the rgW� ng of this per il. 5 APPLICANT U ERSTANDS AND U , MPLY WITH ALL NON-POINT Issued by:5 ORKS Date 0 CE RE ATIONS. Z4 e/ Sig arc or APPlican racer Died e Re-roofs AZARDO MATERIALS DISCLOSURE Type of Roof Ne applicant of future building occupant store or handle haadmous material indefined by the Cosentino Municipal Code.Chapter 9.12.and the Health and Safety .rection 35513(x)? ❑Yes WN. All roofs shall be inspected prior to any roofing material being installed. Will Ihcopplicamor ruwmbuildingoccuponluxcyuipmcnlcrdcviccs which If a roof is installed without first obtaining an inspection,I agree to remove c I ho.mous Cir comami ants ss defined by the Bay Arca Air Quality Management all new materials for inspection. Dinric,? ❑Yes `991Nu .. Ihavcfair Nc hatmmaw T Is requirements under Charter 6.95efthe Califor- nisHcaW/kssfey Sec(ions2550 25533end25534.1nndcrsandthwirthCbuilding Jnr not cement}} ox a anent,No its y omihility m i ndly ded occupent of Ne requirement hichmusthedi pnor mea enlncateofOcc upan9 Signature of Applicant Date Ml 0 Own e ,mwneed „e All roof coverings to be Class "B" or better OWNER-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 performed c. Ge ��o-rut c , p sio 4si �� '1 13 LFLe Q3µ6 i i 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 erformed ..................................................................................................................................................................................... r I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(reverse si Property Owner's Signature: Date: Job Address: Lin j2LO-,-1� , CSA Permit# a 3o!� 007 Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. City of Cupertino Building Departm ' I CITY Of 10300 Torre Aven CVPERTINO Phone: 408 777-3 Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself,you may protect vourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family,and the work (including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding, federal social security taxes,workers compensation insurance,disability insurance costs,and unemployment compensatio contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish,the US. Small Business Administration). For more specific information about your obligations under state law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit,erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors'State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino Printed on Recycled Paper CITY OF CUPERTINO m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng : Sub: Blk: Lot : APN . . . . . . . . . 31621090 . 00 DATE ISSUED. . . . . . . : 08/19/2003 RECEIPT # . . . . . . . . . : 22829 REFERENCE ID # . . . : 03050037 SITE ADDRESS . . . . . : 19997 STEVENS CREEK BLVD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : .VERDE T CAFE (ROSAN LO) ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DENNY UNG CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ------ - ------------- ---------- ---------- ---------- ---------- - --------- BENERGY PERMIT FEE 380 . 00 114 . 00 114 . 00 0 . 00 0 . 00 BPERMFEE VALUATION 35, 000 . 00 380 . 00 380 . 00 0 . 00 0 . 00 BPFIXTURE UNITS 6 . 00 49 . 98 49 . 98 0 . 00 0 . 00 BPLANCHK PERMIT FEE 380 . 00 323 . 00 323 . 00 0 . 00 0 . 00 BPSEWAGE UNITS 1 . 00 62 . 16 62 . 16 0 . 00 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 19 . 98 19 . 98 0 . 00 0 . 00 BPTRAP NO OF TRAPS 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00 BPVENT UNITS 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00 BPWATER UNIT 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00 BPWHEATER PER HEATER 1 . 00 9 . 99 9 . 99 0 . 00 0 . 00 BELEC200 METERS 1 . 00 22 . 20 22 . 20 0 . 00 0 . 00 BPWSVCS WATER SERVICE 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00 PPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00 BREMAPPLI NO OFAPPLIANC 7 . 00 42 . 77 42 . 77 0 . 00 0 . 00 BREMFIXT NO. FIXTURES 17 . 00 18 . 87 18 . 870 . 00 0 . 00 BREMFURN NO UNIT 1 . 00 12 . 21 12 . 21 0 . 00 0 . 00 BREMPOWER POWER UNITS 1 . 00 44 . 40 44 .40 0 . 00 0 . 00 BREMRECEPT NO. OUTLETS 20 . 00 22 . 20 22 . 20 0 . 00 0 . 00 BREMVENFAN NO UNITS 10 . 00 96 . 62 96 . 62 0 . 00 0 . 00 BREMVENSYS NO UNITS 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00 BSEISMICOM VALUATION 35, 000 . 00 7 . 35 7 . 35 0 . 00 0 . 00 BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00 EPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00 MITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00 ---------- ---------- ---------- ---------- L PERMIT 1473 . 94 1373 . 94 100 . 00 0 . 00 R tHOD OF PAYMENT AMOUNT NUMBER CITY OF CUPERTINO m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng: Sub: Blk: Lot : APN . . . . . . . . . 31621090 . 00 DATE ISSUED. . . . . . . : 08/19/2003 RECEIPT # . . . . . . . . . : 22829 REFERENCE ID # . . . : 03050037 SITE ADDRESS . . . . . : 19997 STEVENS CREEK BLVD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER VERDE T CAFE (ROSAN LO) ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DENNY UNG CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , ,TELEPHONE . . . . . . . . : E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- - - ----- ------------ --------------- - -- CASH 100 . 00 TOTAL RECEIPT 100 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION --101--- FOUNDATION ==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 508 FINAL MECHANICAL 509 FINAL GRADE 510 FINAL PLANNING 14 FINAL PUBLIC WORKS