05120039 (2) ;CITY OF CUPERTINOte} pj��t /�BUILDING DIVISION PERMITCo C°j " I�;'""a"'� � '
LDING ADDRESS: KSYC CONST PERMIT NO.05120039
0196 EM
ER'S NAME: PERMIT LSUB DATE
VINCENT CHIN 24704 MA
NE: - SANITARY NO. CONTROL NO.
(510) 726-3182
ARCHRECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� l�
i o p LICENSED CONTRACTORS DECLARATION
I hemby Nino Nat 1 are licensed under provisions,of Ck pmr 9(commencing Job Descriptio
with Section 7000)ofDivisien 3 of due Business and Profession Code,sed my Raman is
I.fall rem�a}ansd ercett Lk 5 710CS * NO CONDITION(((5�����- *f.
7
Date� dm ARCHITECT'S DECLARATIOI
Q 1 understand my plans W used u public recorN KjIJ-/rlNj V' _IV �J, •v1 O /�
) u /1
jamLicensed professional , 1— {.
3 OWNER-BUILDER DECLARATION
`�<S 1 am a alarm on 1 1. memm from ase Contractors Lk•^•-Law for the 1 IV',t��-lj/air V
o O following won.Permit
7f171.5,BasinCss and Profession Code:Any city m county /J
5$
which requires•pemit re comm One aims Wpeaw,demolish permit
a or a sig any stmcturo V $500
i� p W its Is licensed
t0.aiwreto the theapplicant
sof fm anhpermitto Oe Law(rtamment
g < Nst(commencing
withSeswmtothepmvivianaftheConuxmhntanselaw(Cnpm9 Sq.Ft.Floor Area AB valuation
$ (cat he
inawph Section700))andth(DrvWonr oftheeted Business emptlan.my
Code)Or
Net W u attmpt therefrom and da bssu for the stkgee exemption.My yiolWen of
Section 7071.5 by any appllont for a permit subjees,the applicant to a civil penalty of -5 AP14 9FM9FrT U OeWy Type
rot mart thao R.hundred dollars($500). -
❑T.an mmer of the property,on my employees with wages as their mu compenaauon.
will do the web,and the structure Is rot intended Or offend for sats(Sec.RIM.Beaimaa
and Profession Cade The Ontmnm's L kc,law don oat appy N N Want,of Required Inspections
property who builds on improves themon.andwho does such work himself ar through his
own employers.pmWded thm uch improne emu tee Mt Intended moRrnd forst.B,
however.Ne Wilding or impmwmem lasold within ane year ofcompktion,the owner.
Wilder will hams the Maden of praying that bu did non Wild m improv fm purpose of
❑1.as awasr of the property,am exclusively connecting with Respond coatrec7em to
construct the project(Sec.7W.Bounce;and Profession Code:)The Contractm's U.
aepon law don a.,"ply In an owner of pmp ry+W builds Or Tmprows thereon.w,
who contact;for such projects with aconbecaae(O licensed punwnl to Ne Contractors
License law.
❑T am cmmx under Set ,B Is P C for this wan
Owner Des'
WORKERS COMPENSATION DECLARATION
1 hereby ai roe,under penury of perjury am of the fallowing declarWmts +
I tun and will maintain a Ca usicam ofConsom 0 self-ewe fm Workers Compere
73100
inn,u provided for by Section 5700 of the labor Code,for the perfameanm of the
t for which this pcmelt is issued.
I ban arM will maintain Wmimes CompensWan hewnnm,u required by Section
ofthe Labor Code,fm Ne performance of the work fm which this permit en lapsed.Workers Compenssd(o-n�Insurance carrier and Policy number son
rder. SfiA.tP l.NwO PolicyNo.: •L29OU?bS�s
44MF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thu section need Out W camplemd Hine permit is furan hundred Oil=(SIM)
or Wa)
I esaify,that in the performance of the work fon which this permit M iss"I shin not
employ any person In any manor an as to become mbjeO to the Workcm'COMPers,Won
laws of Califamia.Date
Applicants
NOTICE TO APPLICANT:If,after making this CcNDum of Eaempme,you should
become subject to the Wodrers Compensation provision of the Lahr Code,you mus,
.,O (Onhwith comply with such proyidapo on this permit NN W assumed mwked.
r^ CONSTRUCTION LENDING AGENCY
[•+ Ihereby&Mne that dare la a conservation kndingagemy rte the performence of
Q:ti the work far which this Permit k Wood IS..3097.Or.C.)
aQ Lenders None
Z Leaders Address;
V O I certify Nat I Mw mad Nia applleadon and sense dust the W.mfonmatkn u
tL cones.I agme m comply with alt city and county gdinunea and sue laws reining to
O building construction.and Wrathy authorise repeeacoutives of this City to enter upon IN
above-mentioned property fm lespeedan purpmes
G (We)agree to saw.Indemnify and keep harmless the City of Cupertino agairm
liabilities,judgments.nom and expenses which may In my my semen against and City
in V^
APPLICANTr UNDERrantiof RSTANDS ANDWILLWILL COMPLY WITH ALL NON-POINT Issued by: Date /2--
SO ULATIONS.
L� F(c C_7 (Z/Vo(' Re-roofs
Signuumofnppltaanucanwamr Dam of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant ter ratum Wilding Occupant stare whandk hantdon mumiai
as dWned by tim Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yate ?"u
Will the applicant or forum Wilding Occupant on:equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Jmit Incautious air cameminamr as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes PN.
~' Than mad the hvaNmumamrlalsecquiremenu undcrCnpur6.95a1NeCdikr-
Me Hed"SLkaycode,Scctiwn25505,25533 and25.534.1 undcrmn i thatlfda Wilding
does not curmmly new a Wm4 Nat it M my responsibility be entry da meupml or tho
myui menu which mtm Were rtoinuance afa Ceetilkam of OecupRecy.a
t 2 /y� Signature of Applicant Date
Owner on suthmiced agent Dato'
All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Build in ' De artment
JOB ADDRESS: 10 9 6 a M p I pe /j r2 PERMIT#
20 d 3
OWNER'S NAME: Ur,)cep+ C!,i n PHONE #
GENERAL CONTRACTOR: k ea,e-4kk `Cl �� FAX # ? FCS- -7.7 89
I am not using any subcontractors: (L t
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 ata 04tr
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
aolnREPIPE/SEW E I2S/MAIN SERVICE 31
ICUPEkTINO PERMIT APPLICATION FORM
APN # Zb - Z3 D3Z Date: IZ/9/uS
Building Address: 19 t q�
Owner's Name: Phone#:
Contractor: ic.S 5 C Phone: License#:
Genn e�C C4', r\ S l 0
Contact: I`fn^e� Phone: Cupertino Business License #:
Itrc ,,o (-�iA S710-3ZI- 2S19 WC C—f-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Lam]'
Job Description:
1place Sewer Cter,„ IAJ
res,dcfnpt,raolj j� Commercial ❑
ect:
, TOO
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping 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
BUSLIC Business License BUILDING