04020052 CITY OF CUPERTINO k•`M •'- Ca.e '
BUILDING DIVISION PERMIT - AA�„„ T IN)`ORMA• Yp��La
BUILDING ADDRESS: TACHUNG LIN & JUYI HUANG PERMIT ND04020052
OWNER'S NAME: PERMIT ISSUE DATE _
TACH
ONE: SANITARY O. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_op
LICENSED CONTRACTOR'S DECLARATION
pLs I hereby affirm Nes 1 am licensed under provisions of Chapter 9(commencing Job Description
�;;9R with Section 70ME of Division 3 of the Business and Profusion,Code.and my license is I��II��Iil�®
G in full force and effect. ■ice
gqz License Class Lte.g PLUMBING FOR GAS CHIMNEY A
Dare-Contra=
ARCHITECTS DECLARATION yFEB Z O ZOO4
plans shall M used public meet&
1 understand my plu ods Licensed Professional
p 3 OWNER-exemptRD CLARATION
thaCommo BUILDING
4 a 0 I hereby.(Scerre on 1 1. exempt from the Cosions C s c:Any c Law county the
p O following mason.(Semen 7181.5,Business and rte.do ou Cmor:Any city or county
a'$ which require n permit re cored Me alma inttmw,h peopieh,or repair any tWdum
prior redressed p.also ntuiMe thovisiosofcant for sucContecmitaofrleasipw(Chapt em
m�C (home iacingud pedant tothe of Division oMe ftComrxxhndPrselaw(Chapter Sq.Ft. Floor Area Valuation
m $ Min(cohe I.exam with Section 70 4th Division]the
the ageBusiness xempt on.Any
Costs)or
y Nn he is exempt therefrom and or burs for the alleged exemption.Any violation of
Sec Bon 7031.5 five
any applicant for permit subjects Ne applicant m a civil penalty of 3 APNI0104170 0 Occupancy Type
not more then fiw hundred dollar(5500). P Y YP
❑I.o owner of the pmpeny.m my employee with wagu u theirmle compenutim.
will do the work.and theswmum is nothimuch d oroffered Tomah(See.7044,Business
and Profusions Code:The Convector's License law dors not apply he an owner of Required Inspections
property who builds or i mprovesthereon,and ma does such work himxlf or through his
own employees.provided th asuch imprnwmcmu art nalimended or offered for sale.if,
however,the building or impmwment is sold within one you of completion,Ne owner-
builder will have the burden of proving that he did xt Wild or improve for purpose of
sale.).
❑1,as owner of the Property,am exclusively conniving with licensed Nntractom in
construct the pmjem(Sec.7(44,Business and Fortifications Cade:)The Consumes Li.
roue law doe not apply to an owner of pmpersy who builds or Winans thereon,and
who contracts for such pmjecu with aconsnctods)licensed pursuant W the Contractor's
License taw.
❑Into eaemptumder Sec. _\ ,B k P C for this moon
Oiv _"� Dau"is—
Do G/o
O0.Ker Pen PENgrATJp of
fh1 hereby aRsm under penalty of perjury,ore of Ne fo1777555w///ing deduauons:
1 have and will maintain a Cenifiuu of Consent to elf-Insure for Worker'sCompcn-
satimn,ns provided for by Section 3700 or the Labor Code.for the Performance of the
W
ork for which this permit is issued.
❑1 ban and will maintain Workers Compensation Insurance,as required by Section
]700 of the Labor Code.for Ne performance of the work for which this permit is issued
My Worker's Compensation b xnnce carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('(Tis section need not be completed if the permit is foram hundred dollar(Slfp)
or less)
I certify Nee Ne performance of the work for which this Permit is issued,l shall not
employ any Fe many atjn F co the Woflics'Cm,promadon
Laws of lif roe.Dau
APPlicant
N IC 0 APPLICANT:Ir,after making this CcAfmam of Exemption.you ArmW
subject m the Worker's Compensation pmvisiom of Nc Labor Code,you must
.JOfor
with comply with such provisions or Nis permit shall be deemed ranked.
„z„ "" CONSTRUCTION LENDING AGENCY
sN.F
I hereby affirm that More is a construction lending agency nor the
Performance of
!Yi Q the work for which this permit is issued(Sec.3097.Civ.CJ
D Q Lender's Name
]Z (antler's Address
U O 1 codify that 1 have reed this applicmim and soon that the show information is
14 F correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building consvuclim,and hereby xthorix representatives of thus city to anteroom the
6i shove-mentioned he ertysave for impactor!) keep W
(We)agree to arty,indemnify sad keep harmless the City of Cupertino against
rE"a f/1 IiabilWes,judgmenalcosts and expenses which may in say way accrue against mid City
1.consequence of the
of
C) s pcmrdt
APPLICANT UNDERSTAnSDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R GUL BflS. _ �G/ O
Re-roofs
5igne Applm.Hn on Dau
HAZARDO ATERIALS DISCLOSURE Type of ROOF
Will the applicant or future building occupant scam or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.17.and the Health and Safety
Adiflom, 75537(a)7 All roofs shall be inspected nor to an roofing material beim
❑Yea �Nn P P Y g g installed.
Will the applicant or future building occupant sax equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it Ite'rardnus air cmiammants in defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑YetNu
1 have mad the hvallousmaterials requirements under Chmo r6.95 of the Califor-
ria Health 65af ityCodc,Sectlom75505,75533 ud7553E.I understand Met if the building
does not currently haw a¢pant.that it u my msponsibilily to notify the necupam of Ne
myuinomme which,,, prior toosami Ccnifmate of Occupant Signature of Applicant Date
6 ofd
owde a dredamn Data 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 bel / CEj�D
2. A state licensed contractor will be hired to do: FEB 0 6 2004
A. _ All of the work
B. A portion of the work (complete o below)
Contractor Address/City Phone #V State License # Type of work to
be performed
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 sid._
Property Owner's Signature:
Job Address: 7i P7,9 Pers-t# 0 ZD 2 0 U S',
`� J
AM changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenu
C O P E kT I N O Phone: (406)777-3
22
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 yourself 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 compensation
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 U.S.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 Z
REPIPE/SEWERS/MAIN SERVICE o
CUPERINO PERMIT APPLICATION FORM
APN# Date:
Building Address: 12—
Owner's
2—Owner's Name: Q - �� u Phone#: 6 Sv 6S54 2,:)
Contractor: // C ��/ �� Phone: License#:
�fb� 9'er
Contact: Phone: Cupertino Business License#:
L}
Build'n T it Info:
Bld ✓ Elect ❑ Plumb (3
Job Description: I
Pf uwl.'7�A TPo v cw C.kiww.
Residential 0 Commercial ❑
Cost of Project: Z5�
Qty
A li ab e Fee ID Fee Description Fee Group
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bld .Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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