06050067 (2) CITY OF CUPERTINO ^ _ + ' '"o'-- 0,
G DIVISION
A..PERMIT
BUILDINGCS1VT.l2A. ' OR INFO'RMATIU
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BUILDING ADDRESS: s LI ' S CONSTRUCTION PERMITNo.06050067
21915 LOMITA AVE
OWNER'S NAME: PERMIT ISSUE DATE
LUMIN CHANG 654 8TH ST 05/09/2006
E: _ SANITARY NO. CONTROL NO.
(510) 261-8826
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECTO 1OM O
Ipp LICENSED CONTRACTOR'S DECLARATION lob Description
i I anarchy 4rEw Nat r w under
licamcd pm,im m of Cammor 9(comncing
me
vide Section 7000)of Division 3afdm Busiaan and Prollmiom Cade.and mY[I--is
n in full Iowa And effect. INSTALL TEMPORARY POWER POLE
jJZZq
Dam Dow Clm comY
347 ARCHITECT'S DECLAMTION
I undermand.my plans shall W used u public rtcorde r
�Oln Lkemed Prefmfessbnu J
m� OWNER-BUILDER m Ce Conte ON /O/
0 9 1 hereby.(Siam that 1 1. exempt from Ne Cssions o :My c Law o far to v
a O fallowing mama.(Saito 7051.5,Busiaas and Improve.
de um Cade:My city or county
5$An which imissuaPermite.Aw recamtnmLaper.improve.hermit t,rie a sig anyavumure 3
00
I�, thin rbiuiensedpalmentto nu pre inion o for amprarmr's Lia saigded statement
�g thathmemi gwithSrwmttothcpmvivision the oftheBwwr'anmmclaw(Chodc 9 Sq.Ft.Floor Area Valuation
$ thohe Is engwiNSectfon7 send the
Divisionr of Neeged els and empton.my viCoh)of
— Nu k m eswPt Naefmm slid Ne bast gar Ne siteged uwptlm my violent an of
Section 7051.5 by any applinnt Inr a Permit subjects the applicant m a Civil Pew1tY of r Occupancy Type
not mom than five hundred dollars(55001
❑1,u awoer a(0te property,a my wployw vIN wage u Nepmk tampematim.
will do the work,and Ne avuaurt Is not Intended a oRwd wasam(SM.Tie.Busiws
and Prefessiam Cade:The Controllers Lkuoe Law does not apply b an owner of Required Inspections
pmperlywho builds afmprow Nerom.and whodoesaahmall himealfar drawls his
own wplayea,provided was such Imprommmu Are cot Intended aellured(anis.B,
Wenner,Ne buildingar impmwmmt is mid within am year o(oempm W.An awrmr-
builder will have the WNen of proving Nat he did nm build or Improve for purpose of
sok.).
'(W 1,As ow.of ted property w esdasiwly cwuwsag wide licensed wntncmn an .
romtmm the pmjem(See.7044.Business and Professional Cade:)The Contrawra LL
annual law dean not apply an an owner of property who Wilda or Improves thereon,Md.
Who contracts far such pmjecN with a canu9ebr(s)BcelnCd punWnt an the Cotbmmra
Lima law.
❑1.... 1 denSec .B&PSC far
rOil
lm_ssoanv
Owner—i LLLe'ua-- a-rl Dam 5 %O
WORKERS COMPENS ON DECLARATION
1 hereby afferent under penalty of perjury ane of Ne fallowing declarawne:
1 ham and 5001 maintain aCeWBou of Comment in self-edam fa WorkersCampen-
ndon,As provided fa by Section 3700 of Ne Labe Code.fa the performance of Ne
work for which this pewit is imoad.
C I Nve and will maintain Worker's Compensation Taman,As mquind by Section
3700 of the Labor Code,for the performance a(Me aware fa which tills pewit is land
My Workers Compensation lmunnce airier and Policy number w:
Carver: Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE v
(This western mond noted completed if Ne pewit is foram hundred dollars(5100)
or less)
I certify that in the performance of tiro work fa which this pewit Is issued.I shall tot
employ any person in my mmwrm bbce mbj �q�e Workers'CompemWon
Laws err CulramiL Da ,! "
Applicant 'u soul
NOTICE TO APPLICANT`.IL after making Nis Cenlficam of Exemption,you shaub
became subject in the Worker&Compeantion provisions of Na labor Code.you mute
vJ 0 forthwith comply with such provisions An Nu pewit"I he domed revoked.
Z y CONSTRUCTION LENDING AGENCY
[-t Iherehy affirm that then is a construction lending agency for Ne performance of
G'> the work for which this permit is issued(Sac 5097.Civ.C.) '
4 Q Lenders Name
,J z Lenders Addmss
t.)O 1 certify that I haw read this Application and state that the above Information in
ly cower esordordinances;mb
1 agcomply with all city and county ordinances; sum laws nixing
t"
O V building construction,and hereby mtharim mprcalntatimsofthiscity mcnmrupnn the
move-mentioned property for impcc0tn pugmses.
W (We)agree to save,indemnify and kap harmkn the City of Cupertino against
h Ilabilitin,ledgmems.costs and expenses which may in my only amus agumt We City ��vv
^in atmegame or the grandng Of this permh. Date
a APPLICANT 7
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: S
SOURCEREGULATIO .
i S'- Re-roofs
Signature err Ap Xonumiar Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the appliam an its=Wilding aceupmtwre a handle Madam material
As denned by tin Cupenino Municipal Cade.Chapter 9.12,and the Healm and Safety
Cade.Section 25532(&)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Pu
Will the applicant or future Wilding anepant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants n defend by the Bay Area Air Quality Management all new materials for inspection.
DlsWct7 Awt�
❑Yes lq!•u .
I have mad the hnardnm materials requirements under Chapter 6.95 of Ne Gliror-
me Health&Safely Code,Samoan 25505.25555 and 25534.1 tmdc tread Thu ifdn building
deal tat cartn0y Mw mnmt,Nu It is my w"A ibility b tmtifY 0e mupnt of Nc
mquiremenuwhkh be MCI imaWON tf Ocniaamoraaupaay. Signature of Applicant' Date
Owaram ant Dain All roof coverings to be Class"B"or better
Community Development
a0l"
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408) 777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT#
2 6'o °7
OWNER'S NAME: I PHONE # 4
GENERAL CONTRACTOR 2421y2 1 FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
om 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35716068 . 00
DATE ISSUED. . . . . . . : 05/09/2006
RECEIPT #. . . . . . . . . : 34308
REFERENCE ID # . . . : 06050067
SITE ADDRESS . . . . . : 21915 LOMITA AVE
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LUMIN CHANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : LUMIN CHANG
CONTRACTOR . . . . . . . : GOUHONG LI LIC # 27796
COMPANY . . . . . . . . . . : LI ' S CONSTRUCTION
ADDRESS . . . . . . . . . . : 654 8TH ST
CITY/STATE/ZIP . . . : OAKLAND, CA 94607
TELEPHONE . . . . . . . . : (510) 261-8826
OEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BTEMP FLAT RATE 1 . 00 62 . 10 0 . 00 62 . 10 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 100 . 47 0 . 00 100 .47 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 100 . 47 MASTERCARD
TOTAL RECEIPT 100 .47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
j CITE' OF CUP]ERTINO
,EMP SOWER
ERT
SCUP1NO PERMIT APPLICATION FORM
APN# I ^^ h/�p� Date:
lY INIU �-- p
Building Address:
,9 l c'/5 dzou, a,-e
Owner's Name: Phone #:
L 3 -7 G CA e
Contractor: L A C&--Qf-A"r),L Phone: License#:
K (4 os ) rl -s G 3 CP 7
Contact: Phone: Cupetmo Business License#:
Lur+ lAl a,4A^J h C1-4) 37 oC7 Q_
Building Permit Info:
Elect ❑
Job Description:
/ 2 % I 1A2!4
Residentialf I�Y Coniniercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
•