06080015 (2) CITY OF CUPERTINO '�epgynh�a4., � `»;iw"sir-+r<t �
BUILDING DIVISION PERMIT COtY°1Rl�.C$'+�'()R TN'k`URMATTUI
BUILDING ADDRESS: s PERMITNO.O6OBOOIS
21736 COLLINGSWORTH ST
OWNER'S NAME: PERMIT ISSUE DATE
OSHUNGFU SU
NE: SANITARY NO. CONTROL NO.
ARCHITECTYENGINEER: BUILDING PERMIT INFO
BLDG ELO PLUOMB MO
O p LICENSED CONTRACTOR'S DECLARATION Job Description
.ids
FF 1 hm N
hereby&M at i are limosed under provision.of Chapter 9(mmommin{
aids section]OD))of Divi ow 3ofdso Business and Professimu Code,and my lkcose is
t
'H emllfameand,ffcel. INSTALL A/C AT SIDE .YARD
Ltoma,Ct yO Lk.g
Data u Contractor i
ARCHITECT'S DECLARAnON
1 understand my plam.hall be used as public records
t GGG
cad Licensed Professional
1 y OWNER-BUILDER onexempt
from
mDECLARATION ,
I0 I hereby allm on 11. ,sumps font the Camas Co :Any c law fords,
•O o following mason.(Section]1171.5, t,altos and vs,.demolish.
Cod,:Any city m mumy
I$� which requires•Permit to eouuuel alta.Improve,mmalbp,car repair any siruetuo $12400
�^ prior to its issuance.Alm requires Ne applicant for such permit to he a signed moment
j 0 than he is licensed PWWAMaOmprovisions,ofNeContractorsLicetiLaw(011Pter9 S l FloorArea Valuation
i $ commencing with Section 700o)of Division 3 of On Business and Professions Code)or
Nat he Is exempt therefrom and dee bub for the alleged exemption.Any violal{on of
Section 7071.5 by any Applicant ran a Permit mbjeess the applicant to a civil penalty of Occupancy Type
set more than five hundred dollars(5500).
I,ssowm of die propary,mmy wplayeea with vein uNeh mb,anpention,
will do dto workmand it..suumum le not bonded martered fonde(Sec.70/1,Buaircas Required Inspections
and Professions de CoThe Customers License Law den set apply to an owener of q P
min enywha b,provided Out such improve who daeseucMwank himselrmthrough tab
eves employ=,the n,pmWmd than such improvements are set ina:MW m completion.
far Bale.r.
build.',the have
he b r denotement Is told within m Wilde of mPoswf r die owners
builder will hew W burden of Proving Nal he did not hole m Improve far Purpose of
sale.).
E]1.as owner of rhe property,am conclusively contracting with licensed mmrsamo a e
consumer La Ne.project(Sec.7014,Bueesa and property
who u Cade:)The Gtnhoom.Lir /
eau,law does not apply to is owns of progeny who builds m improve Custom and,
1.1c..Law.for such projects with aeanuxvar(s)Oanxd pmawm toNe Canhmior's,
0[am law.
❑lose exempt undo gee .08PC(or thb mason
Owner Dm
WORKER'S COMPENSATION DECLARATION
1 hereby silent under penalty o(podury,now of the following declwtiaos:
1 ham and will maintain a Certificate of Consent to xlMiuurt for Waftes Compen•
sation,u provided for by Section 7700 of the Labor Code,far Ce perfmmate t of the
work for which this permit is issued.
❑1 have and will maintain WwWs Composition Insurance,as required by Seeks
7700 of the labor Cod..for the performance of Ne work fm which this Permit Is issued.
My Worker's Compendapyhi mem carrier and Policy number w:
Cartier. �X P. W Policy No.:
CERTIFI TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7hbnctim need nmbecmnpatted 9 the permit Is(move husdodmBan(SIM)
carless.)
I om ify Nat in the pMmmaocc of the wart for which this t b Isaued,l Nail set
cmploy.ny,Person lnmyman�rfoya�a�a ,su1�ctto orlon'Compensation
Laws of Coliform..Dm / // rrAR
APPlicam
NOTICE TO APPLJCANT:If.spot making this C old ricam of Exemption.you should
become subject to the Worker'.Competition provisions of the labor Code you most
.JO forthwith comply with such provisions m this permit shall he deemed revoked.
E 5; CONSTRUCTION LENDING AGENCY
E
Ibomb,afrtrm Car there b a commucdnn lending agemY or,ft pc,fmm .[
G: the work fm which dds peemit Is Issued(Sue.7041,Civ.C.)
W�Q Lender's Name
7 2 Lender's Addmas
U Q 1 curry thn I have read this apPlicom.W sate that Ne above imomutit0 it
U.i~ CmrtcL I atom a comply with all city and county Ordinances and foe laws rotating in
0 V building construction,and hereby authorise representatives of Nis city to enter upon dte
W ahovcmentiuned property for inspection purposes.
(We)agree to save,indemnify and keep hwmlcss the City of Cupertino against
En Iiabililim judgmcnu,cost,apo expenses which may In my way acauc against said City
t.>,Z in consequence of the granting of this permit.
ry APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date �� 2—sf!
SOURCE RF�EyLAT10 A^ /
�� B �1P D Re-roofs
Signatum of Appllcant/Contrmtor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sort rehandle hazardous matend
as d olord by tie Cupertino Municipal Cade.Chapter 9.11,and the Health and Safety
Code.seay.2ss3x a)]
❑Yos All roofs shall be inspected prior to any roofing material being installed.
40 Will th,applicant or future building occupant six equipment or dcvima which If a roof is installed without first obtaining an inspection,I agree to remove
cosh hazardous air mmminana m Oned by the Bay Ama Alr GuaillY Managamcnt all new materials for inspection.
Di tr ctT
❑Yes No
1 have mad the huardnus materials requirement,under Chapter 6.95 of the Cables.
nta Hc.lth&S.1ctyCam,Smdms25M5.255 3and25531.1urodweW thaifthe building
does 0
0,monody'?42 A tenant I It b rtsponobility to notify ft occupant of the
requirements tbem<t tr ommancenira.tetraca `��,,�` SignatureofApplicant Date
Baa �'f 'tea All roof coverings to be Class'B"or better
Owner ar awharimd.gent Dam"
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OUPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
C0001�?(Xo157
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX # ho a—.sz —t o
I am not using any subcontractors: B/Z �0 0 6
Signature Date
Please check applicable subcontractors and complete the following information
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35617051.00
DATE ISSUED. . . . . . . : 08/02/2006
RECEIPT #. . . . . . . . . : 35490
REFERENCE ID # . . . : 06080015
SITE ADDRESS . . . . . : 21736 COLLINGSWORTH ST
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHUNGFU SU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4709
RECEIVED FROM . . . . : INTELLIGENT QUALITY
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
OE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
______ _____________ __________ __________ __________ __________ __________
BREMAIRHAN NO.UNITS 1.00 10.26 0.00 10.26 0.00
BREMRECEPT NO. OUTLETS 1.00 1.20 0.00 1.20 0.00
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0.00
BSEISMICRE VALUATION 12,400.00 1.30 0.00 1.30 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BUSLIC FLAT RATE 1.00 105.00 0.00 105.00 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 267.73 0.00 267.73 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 267.73 619
TOTAL RECEIPT RECEIPT 267.73
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
QD 8o 0 1 S
CITY OF CUPERTINO
f FURNACE/AC
�UPEkTINO PERMIT APPLICATION FORM
APN# o 35Date:� X91 moos
Building Address:
Z�13 6 Co\H savor}\,• S�• C�.ear�-,�.o � CPQ +F
Owner's Name: Shti S Phone#:
'� `^ 408 -4++•6-a•18o
Contractor: Phone: 4o$-quo-$8B 2 License#:
Contact: rAo,nNbv �A� Phone: qog Ss4— o o Cupertino Business License#:
Building Permit Info: T, v� c j,,,;,i
Bldg ® Elect I2/ Plumb 93-' Mech
Job Description:
Residential 0 Commercial ❑
For Rggidential InAaMations:
Attic U 1" floor LJ 2id floor❑ /
Adhere to min set back requirement 02/
or Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs)❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required El
Cost of Project: 4
°
Type of Construction: Occupancy group: —
Strapped El On Platform Bonded Sq.Ft. F oor Area:
New Location ® Replacement ❑ a•`F°° S F
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10, 000 cf n MECHANICAL
BREMRECEPT Rec tl, Switch& Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING
i-��2'-1-:3