04030046 (2) CITY OF CUPERTINO - �7 `°^� ""�' "'n .& /
BUILDING DIVISION PERMITCONTRAC-TOR INFORMATION �`:,
fI OILDING ADDRESS: WANG DAVID K AND ANNE PERMiTNo04030046
OWNER'S NAME: PERMrr L$UEDATE
NE: SANITARY N9103 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
aOO LICENSED CONTRACTOR'S DECLARATION OpO O O
w '1 haffirmlicensed
that I am under previsions of Chapter 9(commencing Job DescriprAN A LED
Zan ereby withSeen .7flfl()at Division S of she Business and Pfofcssioru Code.and my lime is
in full fora and offset.
5n= License Class Lk.« 200 AMP PANEL MAR 1 0 2004
nt-� Date Contractor
ARCHI3ECT*S DECLARATION
< 1 understand my plans shall he used as public recnNs
G Licensed Professional
a.
BUILDING
so 3 OWNER-BUILDER DECLARATION
.� I hereby aRrtn deal I am exempt from the Comncmrs License Law for the
p 0 following moon.(Section 7031.5.Business and Profession Calc:Any city or county
which requires a Permit to m strvct,arm,.am,.,demolish,ar repair my nrucmm
If
F?i prior In its issuance,also meuiro the applicant(orsuch permit to rile a signed smomcnt
m¢
that he is licensed p..am1.she provisianofMeCmarmum',LianaLaw(Chepe,9 Sq. Ft. Floor Area Valuation
X1-0 (contmcncing wish Section 70111 of Division 3 of Me Business and Profcssimu Code)or
y $
that he is ass mpt themfodm and Ne bass for she alleged exemption.Any violation of
Section 703 LS by airy applicant for a permit subjects she applicant to a civil parsley of rA�Diai,«,g�',s,
oat mom Nan riw headland dollars(ISM). 3 W N4t4?gr0 0 Occupancy Type
❑I,mowmr of Ne proprny,amy employes wish wagau Heir sole compensation,
will do Ne work and Ne swclum is not intended in offered for sale(Set.7054•Business
and Professions Cade:The Commodore License Law does Out apply to an owner of Required Inspections
podpcny who builds or improves thereon.and who doessah work himselfor through his
am employees•provided that fah improvements art nal founded or offered fmsale.If.
however,she building or improvement if sold within one year of completion.Ne pwncr-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,u Owner of Ne propeny,am exclusively contracting wish licensed contractors 10
e muuet Ne godless(Sec.7004,Business and Pentagon.Cade:)The Contractors Li.
me law does not apply to so owner Of,.,ny who Wilds or improves desmon.and
who cantacts(Of such projects wish a caneaerar(s)licensed pursuant to she Contractors
"Lease law.
Ifundus B&PCfermisreamn
Ow.e. / J
WORKER'S COM ENSATIO ECLARA
1 hereby sf irm under penalty of perjury one of she following decsmtians:
J J l have and said maintain aCerdficme ascertain to self-IM1WR for Workers COmpen
sation,as provided for by Section 37M of the Labor Code,for Ne perfomenm of she
work for which this permit is issued.
❑I have and will maintain Worrier's Comperuation Insurance.as rcluiad by Section
3700 of the laWr Code,for dee performance of the walk for which this permit is issued.
My Workces Compensation Insurance carrier and Policy number ane:
Carrier. Policy No.: _
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
Qhs accum rad not W eomplcmd if the permit is for one hundred dollars(SIM)
ar less.)
I certify that in the performance of the work for which this permit is issued.I shall Out
employ any,Pcrmnin wijecomg subject total Workeri Compensation
Laws of Cabfo 6 tt o -
APPlicanl gs L( i
NOTICEU4 APP :I•e ser making this Cenificatc of Exemption,you should
become�i met to she Warker's Compensation previsions of the labor Cale,you most
.J 2 forthwith comply with such prenvisim or Chia pomp shall be decmcd revoked.
zO V CONSTRUCTION LENDING AGENCY
P:tz, Ihands,afrm Ma,mert iso caruweum lending ages,for ft pcifomanm of '
^.G? the work for which this permit is issued(Sec.3097.Civ.C.)
W lender's Name
Dn Lender's Add.
:D'7.
O Q 1 certify Nat I have mad this application and sea:that the above information is
F' cofmcL I agree to comply with all city and county ordianca and sum laws reclating to
pU Wilding emistrunion.and herehymummoe representatives Ofdrf city to cult,upon the
above-memmcd property far inspection plop.
(We)egret Io ane,indemnify and keep harmless the City of Cupertino against
F" Ta'A
liabilities judgments,costs and eapcnsa which may in my way accrue againsnsaidCity
U Z in consequence of the graining of this permit. r
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITHLL NON-POINT Issued by: Date
s URCE REGUL ONS -7.
l° Re-roofs
Sr - rc of ApD'is ntraan Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser fuwre,building occupanutare or handle hrrardous material
aa de0md by the Cupertino Municipal Cods,Chapter 9.12,and the Health and Safety
.sr ly.s s3xan 9�a - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or forum Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants a dcfncd by she Bay Arca Air Quality Management all new materials for inspection.
Dstrin?
Ycs dNo
1 have read the monism,materials requirements underChapter6.95urge Califor-
m. alth&SarelyCode.Sections 255(15.25533 and 25534.1 undcrsmnd thou done Wilding
dors not curmmly haw a means.Lha it is my hamomibility In has tM"'Incaparr of the
requirements which orow
qe, �ifs mora Ccnifes affxcupmc Signature of Applicant Date
( °"— " '�45"a 'zo -
0euthorivcd All roof coverin s to be Class"B"or better
a rat Date g
Community Development
I
ZIA,
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS PERMIT #6 U 2,
OWNER'S NAME: JC 3 g IUC-7 PHONE # — p
GENERAL CONTRACTOR: / FAX #
I am not using any subcontractors: tel` lcXl-
Signature '/ v Date
Please check applicable subcontractors and complete the following information:
61 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass/ Glazing
-----/'1r-Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
caner/C ntractor Signature Date
a(Iffl- CITY OF CUPERTINO
CITY OF
CUPEkTINO PERMIT APPLICATION FORM 01 o
APN # Date /B
D vLk
Building Address: L Mailing Address (if different from building address):
Owner's N51:
Phone #
Contractor: r License #:
0("ex u :Ja.l 49
Contact: Phone- Cupertino Business License#:
B ding Permit Info-
91
W
lect [ Plumb ❑ Mech ❑ption:l V UfJ '�/� �CLs-cG L Commercial ❑
Sq.Ft. Floor Area: � ,ry $/Sq.Ft.:
Cost of Project: CU Occupancy Group: r
Type of Construction: p Please check this box f Ject is a
✓�'� second-sto addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
1 BELEC1001 Elec 600V > l 000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILD G
z � 7-3
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7
L - CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> IOK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
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CITY OF CUPERTINO
CITY
CUPEf�TTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMTHEATR Theatrical Ligbting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
M
BREVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporairy Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Change BUILDING
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