04060194 CITY OF CUPERTINO "
I bA'p a
BUILDING DIVISION PER413ALira
BUILDING ADDRESS: ELIM HUANG PERMIT NO 04060194
22195 VIA rAMTNQ rT
OWNER'S NAME: PERMITISSUE DATE
ELIM HUANG
NE: SANITARY N0. CONTROL NO.
7ARCHITE-CTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0LICENSED CONTRACTOR'S DECLARATIDNUI hereby affirmthat I em licensed under provisions of Chapter 9(commencing Job Description
Section 700ardDiv.m.3ofdte Businasand Pofessions Code.end my license Is
c� u fore,and effect. DEMO
�Z License Close ss Contractor Date Cuntrutor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public rccoms
a �>
3 Licensed Professional ^�7^
OWNER-BUILDERexemptDECLARATION V ref
2 f I hereby mean a0irm that I em exempt from Nc Contractor's Co License Law for the
w20 following rem...(Section 703 1.5,nosiness and vve,Professions Code:Any city someone county
_ which requires a permit re ennvmn,alter.improv,dcermit1 or mpSig ed taeu
c�< Pnonn its issuance,galso ntto the theapplicantof for such Connector's
icese Uwdsummcm
that hers licensed pursuant of Division
the Contracmr'andProf fawnCock)
(Charter9 Sq.Ft.Floor Area Valuation
(eat he
(commencingwith
and of pivision3 du Mlegcdnessondon.fAny vi CMc)of
ey..
that he u exempt therefrom and dte baso for Ne Jlegcd Gumption.Any violation of an'��
Section 7031.5 by any applicant for a Permit Ne applicant to a avil penally of O QIR*erO O Occupancy e
not mart Nan five hundred delta.($5130). P Y TYP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work end Ne swmum is not intended or offered forsam(Sec.7044,Business
Ad Professions Code:The Conuacter'a License Law does not apply to an owner of 'Required Inspections
property who builds or im proves Iheuon,and w ho doess uch work himsel f or through his
own employees.provided Net such improvements ere not Intended oroRered for sl..IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that M did not build or improve for persons of
rsalc.).
1,as owner of du property,am exclusively convecting with licensed contractors in
construct the pmjen(Sec.704,Business and Prafesuans Code:)The Conlmnoh Li�
cause Law does not apply N an owner of property who builds or improves Neuon.and
who contracts for such projects with a comracmr(s)licensed Pursuant M the Con o cuts
rcense Law.
ll�fl am exempt under See. ''��/- ,B k P C for th'a moon
Qwner D. � L U
vWORKERSCO PENSAD LARATION
I hereby affirm under. 1y of perjury one of the following declaration e
,]I haw and will molecule a Certificate ofCamsem to self-insurt for Workers Comfier.
salon,se provided an by Section 3700 of the Ube,Code.for the Performance of the
work for which this permit is issued.
❑I haw and will maintain Worker's Compensation Imuran.,as required by Section
3700 of NC Labor Code,for the performance of the work for which this Permit is issued.
My Worket's Compensation Insurance artier and Policy number au:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need an,he completed true,permit is Boon,hundred dnllus($100) _or less.)
1 certify that lhihe performance of the work for which this Permit is based,I shall not
employ any pc. ymanners.aa�NL ..su�clfojlyf WorkeWCompenutlan
La ws of Callifo i Dem La+ t b Y T
A platen
N TO APPL ANT: , Rrtr making this Cenifimuc of Exemption,you should
We a subject to Nm
Ne Woher I mPcdend provisions of Ne Ichor Com,you most
.JO forthwith comply with auch pro air.or Nis permit shall he dastarduv.kcd.
.Zi r CONSTRUCTION LENDING AGENCY
(-+4 I hereby affirm Nal Neu is a convection lending agency for dm Performance of
lyr 7 the work for which thle permit is issued(Sec.3097,Civ.C.)
W Q Undoes Name
=z Lender's Address
U C) I certify that I have read this application and sate that the be.information ix
ka f+ credits.1 ague to comply with all city and county on inances and state laws minting to
�U building convection,and hereby authmiae representatives of this city to,mer upon the
ncid
cn shave-menudgme Property for inspection which may
V`""G�N
6t (We)agree to aa.,indemnify and keep harmless the City of Cupertino against
t+V1 liabilincoiJes,jncia of ts,csuand ranting of this esmit. mayin any way accnu against mid City
U APP IL CANT UNDEthe RSTANDSIAND WILL COMPLY WITH A4L NONPOINT Issued by: Da
i,
OURCE REGULAT
`'� 6 fir- Re-roofs
Signatures(AppliamVis tar Dim
HAga OUS MATERIALS DISCLOSURE Type of Roof
WIll Ncapplicantor mrc building.cupmlarore or handle hesmous materiel
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
Code,Section25532(a)7
❑ . NAll roofs shall be inspected prior to any roofing material bei. installed.
Will the applicant or f�gebuilding occupant sea,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hnsmnm air.n.miname s defined by the Bay Area Air Quality Management all new materials for inspection.
District? ,/
❑Yes f.
I have mel the ha saimomaurialsrequircmenu under Chapter 6.95 of thc Califon
ria HcaW h Safety Code,Setif..25505.25533 and25534.I unde.und thinfo.building
Jots not cordially have a Woad,that it is my responsibility to notify the occupant of Ne ..
rcquircnrhich must prior m ism ancc CcrdficaN of cupenc.
t y ,41 Signature of pplicant Date
Owner or authorized agent te All roof coverings to be Class"B"or better
i
CITY OF CUPERTINO
OM1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32646021 . 00
DATE ISSUED. . . . . . . : 06/22/2004
RECEIPT # . . . . . . . . . : 26027
REFERENCE ID # . . . : 04060194
SITE ADDRESS . . . . . : 22195 VIA CAMINO CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . :
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ELIM HUANG
ADDRESS . . . . . . . . . : 22195 VIA CAMINO CT
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : YAT LEUNG SUM
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : ELIM HUANG
ADDRESS . . . . . . . . . . : 22195 VIA CAMINO CT
CITY/STATE/ZIP . . . : ,
TELEPHONE
QEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
13PERMFEE VALUATION 8 , 000 . 00 137 . 00 0 . 00 137 . 00 0 . 00
BPLANCHK PERMIT FEE 137 . 00 116 .45 0 . 00 116 .45 0 . 00
BSEISMICRE VALUATION 8 , 000 . 00 0 . 80 0 . 00 0 . 80 0 . 00
---------- ----------- ---------- ----------
TOTAL PERMIT 254 . 25 0 . 00 254 .25 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 254 . 25 M/C
TOTAL RECEIPT 254 . 25
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
704 DEMO
•
0 CITY OF CUPERTINO
0c, DEMO
CUPSR.TINO PERMIT APPLICATION FORM
• APN# Date:
i 7
Building Address:
22/ S V•r4 44A-avo ¢;/-
Owner's Name' �-L,M Pho e
'�5 ��oBJ 202-65'p�
Contractor: R License
Contact: " Phone#: 2
t�� J12
' �
Applicant/Contractor:
Building Permit Info: _
Bldg Elect �— Plumb Mech "'—
Job Description: /tra,-/ ern
Residential: wv 57a s- Commercial:
"
Sq.Ft. Floor Area: $/Sq.Ft.:
2oe� s
Architect/Engineer: h Valuation: ��
Type of Construction: Occupancyoup: _,
Q
Apt li le Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG