05080228 CITY OF CUPERTINO ¢a't94'�dxisa }. 't-+.Frv'' iwd
BUILDING DIVISION PERMIT CONTRACTOR INkURMATTQ
BUILDINGADDRESS: ABLE SEPTIC PERMIT NO.05080228
OWNER'S NAME: PERMIT ISSUE DATE
JERRY CHOU S20 RRRn 9T OR/21;/9.00c;
3NE: SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDOO O PLUMB
MECHO
LIOZ LICENSED CONTRACTOR'S DECLARATION JobDescri do„'{I1
I hominy"Men that 1 am Immune under provisions of Chapter 9(commencing P Yf (a��{ryp r /r'f7
with Section 7M)ofDivWon Sof dw Business and Profcasios Code,and mylicenmis If INA
ED
J2 windlac. (7 f�175 SEWER LINE HOOK UP (120 ' ) 33
e Dau R-2 A CSImmunAlilse
DEC
ARCHITECT'S DECLARA ls
I undersand my plant shall be used as public recnms Sep /�3 ?005
3 u
red
Licensed Professional SS
5� Oat I am exempt
in DECLARATION
i E I heathy.prem that 11. exempt from the Contractor's o License Law for to
Ea
O O which ng won.(Saito RD l.0.Business and wc.&Moes Code:Any city or county t.
$12 whish requires a Permit m cane,the alcor.ht for such
h pcomiit t"mPalr any suucure t '0 O
F P prior at the i a issuance,licensed
purso mqo the UN applicant far such ector'to1cons,hew(Cha mem
g � NalheisllcenmJPunuenunthOPmvialonsofthe ConuecmrYLmcnmisw(Chapmr9 Sq. Ft.Floor Area Valuation
a $ (Commencing with S=6on70DO)of Divblon3ofdm Busin and Profeuiola Cude)m
..
that he"Is exempt therefrom and the basis for the alleged evsptton My violNon of
Section 7031.5 by arty appllunt for a permit subjects the applicant to a civil Penalty Ofe 0 0 Occupancy Type
not mom than five hundred dollars(S500). P y .
❑I,Is owner of Om property,army employees with wages as their sale compensation,
will On,the Werk,and llasbuelum is not InarWed"oRmed forsak(Sm.To".Busineu
and Profession,Code:The contractors LiaLaw does Out apply to an Owner or Required Inspections
property who build,or im proves thereon,and who does such work hiatal f or through his
Own employees,provided that such improvements are notimended mo@rtd f"We.If.
however,the building or improvement u mid withal one year of completion,the manes '
builder will haw the burden of proving that he did nm bald a Improve for purpose of
❑h as owner of to property,am exclusively contracting with Ilcetmd convactora an
convect the project(Sec.7044.Business and profusions Code)The Otherwise,U.
cents Law does not apply as an owner of property who builds or hnproves thereon,and,
who contracts for such projects with a conmmor(U licensed pursuant to the Contractors
Licence Law.
O l am mueept under Sec. ,B k PC fm this mama
Owner 9U fiU /.l Drm
WORKER'SC MPENSATIONDECLARATION
1 hemby afam under pmWty of perjury om of the following declmilam
I have and will mainuin a Cemeaw of Coesent w self.imam roe Wahee,C=Nn.
don.a provided for by Section 3700 of the Labor Code,for the performance of me
work for which this permit It issued.
❑1 hew and will maintain Workees Compensation Imumna,u required by Section
37110 o(dm laborCde,for the performance of the work("which ria permit is issued.
My Werkee,Compensation Insurance ani"and Policy number am:
canes 5 t'atL "e A el Policy No.: j 5 5 A I S 7-e l
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu maim need cot becomplead Rlhe permit bf"ane hundred dollars($100)
tor mus.)
1 certify that in the performance of tho work for which%is permit is issued,l WII not
employ my'persue in my manner so u to become subject to de Workem'Campematon
Laws of Califomie new
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifca m of Exemption.you should
become subject to the Worcees Compemadon provision,of this Labor Cade,you must
0z forthwith comply with Such Previsional Or this pemil shelf he denmed revoked.
Z CONSTRUC ION LENDINGAOENCY '
D;
(~ k ror which mthat permit is a construction 3097.lending agency Por the Performance of
!Yi 7 the work f"which this permit u cured(Sm.3097,Co.Civ.C.)
0.Q Lendan
Lenders Na
]z 1<ndeeaAdw
U 0 1 Certify that I have read this application and slate that the,bow Information i,
(g,;'". COMM 1 agme to comply with all city and county uNlnsom and sum law mlating to
0 rV' building cmmucton.and hereby mutation representatives of this city In enter upon tat S)
LU abow-OOMMO 4 Property for INP,mtoa Puriwes
(We)agree to save.Indemnify and kap hermmas the City of Cupertino against
y liabilities,judgmcnu,costs and expenses which may in my my game against midCity
U Z in consequence of the grunting of this POrmiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINr Issued by: Date C 2_r—_enp—
SOURCE REGULATIONS.
�l K-2S�o`7
Signuurea�App �an or Re-roofs Dam of Roof
HAZARDOUS MATERIALS DISCLOSU RE Type
Will the applicant or future building Occupant naw Or handle hens dour manurial
as deRncd by the Cupertino Municipal Code.Chapter 9.1x.and the Health and Safety '
code.Section 25532(a)7
❑Yea QNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hammnas air cmtaminma as kflncd by the Bay Am,Air Quality Management all new materials for inspection.
ss n7
13 yes 2�vu
I have mW the basement materials requirements under Chapter 6.95 of the Califor.
nu Head"d:SafmyCede,Sessions 75505.25533 and 255X.1 udonatwld That lithe beimet
does cot curteonly have a Numb this it u my msporeuiiny m notify the meu ant of the (-&),I(-&),I (/it —Zai—a'
Mquimmcnu m
which mux b: elimorto issuance of•Ccmrlc,N of Occupancy. Signature of Applicant Date
tz t'. �3 a Oi—'Z5—p
Owner or aotfionved agent Dam All roof coverings to be Class"B"or better
ar
Community Development
10300 Torre Avenue
' 1 Cupertino CA 95014
Telephone(408)777-3228
CITY OF . Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT#
B q l7 7r,0 VS-45
cp-
OWNER'S NAME: JT-t;YYy C h o v PHONE # 4ol 569
GENERAL CONTRACTOR: N, FAX #
I am not using any subcontractors: Cz W_0
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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 , /
/`{{�� __t -c-0 t i LZ/Y? yL, 5
Owner/Contractor Signature Date
CITY OF CUPERTINO
AS;
REPIPE/SEIVERS/MAIN SERVICE 4 S�� ° z
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 0
{� 7 D e� ZCI _ orj
Building Address:
O 1-7 c/ C, _
Owner's Name: Phone#:
J,-Cyyv c k d L/ N6 f ) 5 6 9 — 49 q,3 V
Contractor: Phone: License#: `t y-715
hl l vnd c21youa 0 ,g -7 7 qq to [- BIZ
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
5 -c w eY u u R 1,40 OF e wti aI n
Residential X] Commercial ❑
Cost of Project:
�J oOm
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bld . Permit Fees BUILDING
BPGAS Gas Pi in&System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
.4 7/�