08060084 (2)CITY OF CUPERTINOaxt"F
BUILDING DIVISION PERMIT
@ONTRACTQR INFORMATION �$
V"
*V,
BUILDIN ADO0.E55:
PERMRNO.
22 45 CUPERTINO RD
PROVISION DEVELOPMENT, INC.
08060084
OWNER'S NAME:
PERMIT ISSUE DATE
KEV.T.N POON
1288 KIFER RD STE 207
06/11/2008
NE:
SANITARY NO, CONTROL NO.
(408) 245-0991
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR' DECLARATION
limaned Claimr9
-
Job Description
1 hereby affirm that I am under provisoes of (waning
with Section 7") oroivicon 3ordm Bmdoev and Pmfeviam code. and my l4enau
TEMP POWER PERMIT
in full to= and effect. -- Q
Liceesc Lle.a
Dam Contramr
ARCHITECTS OECI A ATION
1 understand my plans shall be used as Public records
Licensed Professional
OWNER-BUILDER DECLARATION
'
I hcmby affirm that I am exempt from the Cdnmaetons License Law for the
following myon. (section 7031.5. Business and PmfeWoru Cade: Any city or county
which requires a permit to eanauuct alcor, improv,:, demniich, or repair any Mumma
Prior u, its issuance. also Rquirea the applicam for such permit m rile a signed statement
that he u licensed pursuant to the proviaides of the Contncuar's hetet I.. (Chapter 9
Sq. Ft. Floor Area
Valuation
(cmmomach g with Semi. 70W) of Division 3 of the Business and Professions Coda) or
$200
that he is exempt therefrom and the basis for the alleged exemption. Any vialatian of
Occupancy P Y Type
Sachs. 7031.5 by any applicant res a Permit subjects the applicant W. Mil penalty ofNumber
nope Nan fi
t mow hundred dollars (M).
32616035.E
L ewher df tiro pe,tMem. a mY amp wages ss Heir rale Lmmpewdon,
cratedwith
will do Ne work, and the he c.. u mos Licdcd dfa w donfor Wepply to a, Barimae
o
and code: The Crnmac License Law dace net apply m rd owner rr
Required Inspections
propertywho
property bis thereon,and who dossuchwank himselrDrthrough his
on.
a, proorimpraw
own employes,provided that such impmromens tae not intended If.
year completion,
hander the buildingor mplati n. sfor he owner.
tuies of Merttieholdwdidnee
builder will love dm bmdrn of proving that Ise did rot build w improve for puryase Df
a purpose
Wo.).
❑ 1, a awe of the property, and escludroly communing with Raved contractors as
wmuu l the project (sec. 1044. Business and Profesdrru Code:) not, Caatramoes U.
cense Law does not apply m an owner of pmpeny, who builds or improves thereon, and.
who contracts for such pekes with a eonuanor(s) licensed Pursuant us one, Communes
Llmdae Law.
O l sm exempt under Sea ,B k PC for this mann
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 Mreby efftmt under penalty of perjury .of the following declarations:
❑ 1 ham and will maintain a CenifiatedfCommrt to W f-imurr dor. WerkcraCompeer-
holder, a provided for by Section 37M of the Labor Code. for the performance of the
wort far which this admit is issued.
❑ 1 baro and will maintain Worker's Compensation learomm. a required by Section
3700 of Ne later Code, far the performance of the work forwhich this permit is lamed.
My Worker's Compensation Insurance artier and Policy number am:
'
Cartier. _ $` /f��- �U N n Policy Nr.: D Ak9l'%— VV(,
Policy
1 C Fl TE OFE FROM WORKERS'
COMPENSATION INSURANCE
finds semhm heed not Ise completed if the permit Is (mane hundred dollars ($100)
or less.)
1 certify Not in the perfmmam of the work for which this permit is issued. l shall not
employ any person in any manner so as W become subject to the Wdrkms' Compevnirn
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL aMr making this Certificate of Exemption. You should
become Ma. m the Wooler'. Campevkum, pro.isiov of the labor Cs, you mow
founwill comply with such pmvivmu or Nu permit Nall W deenmd revnkcd.
-
CONSTRUCTION LENDING AGENCY
I botany sperm that then is a commose inn lending agency, for the parfunnana of
the work fur which this permit is issued (Sec. 3(Y?7, Co. C.)
Lender's Name
lander'. Add.
I comfy that I hero Rad this application and sum that the show information is
conte. I agree to comply with all city and county ordinances and sum laws relating to
building construction, arW hereby authddre Rprvemall. of this city m cnmrupan the
Mem-mentimmd pmperly for inspection purposes.
(We) agree to exec, indemnify and keep hatmless the City of Cupertino against
liabilities, judgmcns. cors and e.pensca wni�6me way acrnm.gainst said City
in consequence of dm grating ofs
APPLICANT UNDER AN L COMPLY WITH ALL NON-POINT
SOURCE REG Ns.
Issued by: Date
6 // 0
Re-roofs
41lgnYUR (ILLI ARDOU ate
HAZARDOUS MATERIALSDISCLOSUREMom
Type of Roof
WIII dm applicant a future building occupant rem Brandthandle
or materiai
Hcasdry
de. ed by dm Cupertino Municipal Code. Chapter 9.13, and the Hualth and Safety
Code, Sectiony35533(x)?
C
Ya No
All roofs shall be inspected prior to any roofing material being installed.
Wipe the applicant or fat rebuilding ..Pa., um cyuipmem or devise which
If a roof is installed without first obtainingan inspection, I agree to remove
P g
emit haardnes air contaminants as, defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes a
I.aro taWtM requiChapmr6.95afdCaiifdr.
nuHuMkSafetyCdm3 S34.IuJas
Rm-no's
setcurtanOY heroit' mspdawn,,tymrotifYdmrtquirtmenu
whichm of. Team of 04�n
6 /1770,18
Signature of Applicant Date
All roof coverings to be Class '%;" or better
o roraudurindagcnt I Dole
• 4 ITEMS OF 4
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32616035.00
DATE ISSUED.......: 06/11/2008
RECEIPT #.........: BS000005071
REFERENCE ID # ...: 08060084
SITE ADDRESS .....: 22245 CUPERTINO RD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: pdtg
COPY # : 1
OWNER ............:
KEVIN POON
ADDRESS ..........:
22245 CUPERTINO RD
CITY/STATE/ZIP ...:
CUPERTINO CA, 95014
RECEIVED FROM ....:
JOHN HA
CONTRACTOR .......:JOHN
HA . LIC # 29054
COMPANY ..........:
PROVISION DEVELOPMENT, INC.
ADDRESS ..........:
1288 KIFER RD STE 207
CITY/STATE/ZIP ...:
SUNNYVALE, CA 94086
TELEPHONE ........:
(408) 245-0991
• FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
1BSEISMICR
VALUATION
200.00
0.50
0.00
0.50
0.00
1ELCPLNCK
HOURS
1.00
122.38
0.00
122.38
0.00
1ERT<200
UNITS
1.00
40.79
0.00
40.79
0.00
ITRAVDOC
FLAT RATE
1.00
----------
40.79
0.00
40.79
0.00
TOTAL PERMIT
204.46
----------
----------
0.00
----------
204.46
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT
AMOUNT
---------------
204.46
---------------
204.46
VOICE ID DESCRIPTION
-------- ---------------------------
402 TEMPORARY POWER
•
REFERENCE NUMBER
--------------------
VISA
VOICE ID DESCRIPTION
-------- ----------------------------
•
SUM
CUYOF
PEIOTC R,T
INO
L
E
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
APN #
�2G (P� 3S, vv
Fee ID
Date:
6' z3�
Building Address:
Permit Type
22Z S C of vni o o I -v _ GO�c ,rr o
IERT>IK
Owner's Name:
E
Phone #:
KeewtN coo fl
IERT<200
(�Sb)-703-333
Contractor:
Phone#: Z¢S'_Ogq
pi�uli�SlorJ bmf - (NL
Res. Temp Power 200-1 K
Amps
Fax#: 831
Contact:
Phone #:.Z4S -09�
Contractor License #: �- 3
E
Cupertino Business License #: �
O � LI
Job Description:
Electric Plan Check
fiu—m F r owe &-r-M, ;
Residential k,
Commercial ❑
Valuation (cost of project): 9-0-d
B
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IERT>IK
Res. Temp Power >IK
Am s
E
1REAP14
IERT<200
Res. Temp Power <200
Amps
E
1 ERT2001 K
Res. Temp Power 200-1 K
Amps
E
I EPERMITFE
Electric Permit Issuance
E
IELCPLNCK
Electric Plan Check
E
IBSEISMI—CR
Seismic Residential
B
ITRA VTD—OC
Travel & &Documentation
Fee
B
CITY OF CUPERTINO
TEMP POWER
OF
CUPERTINO PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1BSEISMICO
Seismic Conunercial
B
10EAP14
IECT<200
Commercial Temp Power
<200 Amps
E
IECT>1K
Commercial Temp Power
>IKAm s
E
1 ECT2001 K
Commercial Temp Power
100-1 K Amps
E
1TRAVDOC
Travel & Documentation
Fee
B
1BUSLIC
Business License
B
•
0
Ist-
CITY OF
OUPERTINO
•
LJ
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
2a2 '69'(. 61 o YLO .
PERMIT #
(--1) Fs c7 6 O8 y
OWNER'S N E; "-4 fWD
PHONE #
GENERAL CONTRACTOR: (I o -V 15 i o r1 O J o -4 G .
FAX-#
I am not using any subcontractors:
Please check
— Signature
and complete the following information:
6' (11 6 g,
ate
Owner/Contractor Signature Date
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