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03070230 (4) CITY OR CUPERTINO null.0lrvc Dlvlslory PERMIT aC�NTR ACTORINI' ATg . BUILDING ADDRESS: PERMIT NOO 3 0 7 0 2 3 0 nj� ER'S NAME: PERMIT ISSUE DATE XIAO SHI 2003 PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERM IT INFO BLDG ELECT PLUMB MECH +op LICENSED CONTRACTOR'S DECLARATION JobDescri [ion C 1 hereby affirm that 1 dm licensed under provisions of Chapter 9(commencing p T with Scetion?")of Divi.ion3oldm Busheastnd Prm(c.ium Code.and myliccme is in mu ln.eand alfact. REPLACE WINDOWS iq: License clan Lic.x Can =� Dille deada pu 1 ` e SS ARCHITECTS DECLARATION 1'£--"/1 e W U I understand my plans shall W used u public rtcnrds EXP 6`off Licensed ProfessionalgOWNER-BUILDER DECLARATION <I 1 hereby.IBrm that I am exempt from the Contractor's License Law for theO o following matrn.(Section 1131.5,Business and Prufessimrt Code:Any city or county5 � which requires a peril to construct,alter,improve,demolish.nr repair anystructure $5000 to prior us its issuance,also requires the applicant for such permit o OIc a signed smmmem that he is licensed pursuant to the provisions of the Contractor's Liconse Law(Charter 9 Sq.Ft. Floor Area Valuation lcommencing with Section 7")of Division 3 of the Business and Professions Cmm)or thgt he Is exempt therefrom and the baeu for the alleged exemption.Any violadon or 36908037 . 00 Stenon703 L5 by any applicant for I permit subjects the applicant to a civil Penalty of APN Number Occupancy Type not more than Eve hundred della.(5500). ❑I,uawner of the propcny,ar my cmploycu with wagmu their sole compen.tion, gill do the work,and the tomato.I.not intended or.!Brad for W.(Sec.1044,Busioss d Inspections tind Professions Code:The Contractor's License Law dons wt apply to an owner of 102 — PIERS p propeny who builds or improves Hereon.and who dos inch work himself or through his own employers,provided that such improvements art not Intended or offered for sale.If, 103 — UFER however,the building or improvement is sold within one year of completion,the owner builder will ban the burden of proving that at did nut Wild or improve for purpose of 104 - REBAR 105 - ANCHOR BOLTS "'e2 as owner of the property,am exclusively contracting wi th licensed contractors to 106 - SEWER & WATER construct the project(Sec.]Odd,Business and Professions Code:)The Contractor.Li- a...Lawdoes nalapply toanowner ofproperty who hills orImproves,themon.and, 202 — UNDERFLOOR PLUMBING who mmtlawu Bar such projecuwithoconwnorD)lsensee pursuant the Contractoh 203 — UNDERFLOOR MECHANICAL ❑Iam exempt tat( Seo. .B&PC for Nis recon 204 - UNDERFLOOR FRAME am W 205 - UNDERFLOOR INSULATION WOR RE 'S COMPENSATION D ATION I hereby M.under pemlty,of perjury arc of the following deelarniom: 3O1 — ROUGH PLUMBING ❑than and will maintain a Certificate of Consent to self-imum for Wormtscompem 302 — TUB & OR SHOWER .lion,as provided for by Section 3100 of the lam Code,for the performance of the 303 - ROUGH MECHANICAL work for which data permit is issued. 304 — ROUGH ELECTRICAL ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3 05 — FRAME 37M of Ne labor Code,for he performance of the work for which this permit is issued. My Warmer;Compensation Insurance carrier and Policy number rt: 306 — HOLDOWNS Carrie Policy No, 307 - INSULATION CERTIFICC ATE OF MPEN ATONIMSURAANEON FROM ORKERS' 308 — SHEETROCK (fhiascmion need nolkcomplemdlfthe permltbforenchundroddolla.($100) 309 - EXTERIOR LATH 310 - INTERIOR LATH I cenify that In the performance of Ne work for which this Permit is issued.I shall not 311 - SCRATCH COAT employ any person in any manners.as to become subject to WorkeK w Competien Law$of California.Data 313 - ROOF NAIL Applicant NOTICE TO APPLICANT%IL efmr making this Ccnificau,of Exemption,you should 501 - FINAL ELECTRICAL ENERGY become$Object to the Workers Cmmpcmation provisions of the faMr C1Me,you must �!Z forthwith comply with such provisions or this Permit shall he deemed rename. SO2 — FINAL PLUMBING ENERGY ZO CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY I hereby affirm that there is a eamuuction lending agency lar he performance of 504 - FINAL BUILDING ENERGY z> thework to,Ouch this permltisissued(See.3097,Civ.C.) Under's Name 505 - FINAL ELECTRICAL 11 A Under'Addm.. 506 - GAS TEST ;,)Q 4 1 certify Net 1 have reed Nis application end sum that the above infonnaliun is 507 - FINAL PLUMBING Y H correct.l agree to comply with all city and county ordinances and sum laws totaling m V building construction,and hereby authorim representatives afthis city to enter upon the FINAL MECOHAN CAL hove-mentioned I-as forinspection purpnses. "I17 (We)agro m save,indemnify and keep harmless the City or Cupertino against 0 9 FIN ti U1 Ii:bilhies,judgments,costs and expen<••which may in any wry&come againet said City 5 A NG J z in APPLICANTclINDI RSTANDSloading of Ihis Permit- AND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Dat SOURCER ONS. /(2) Re-roofs Igoe plicanVContracmr etc HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant r future building occupant store or handle locum eus material .donned by the Cupenino Municipal.Code,Chapter 9.13,and the Health and Safety ode.Section 15533(.)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ]W No Will the applicant or future building Occupant use equipment ordcvims which If a roof is installed without first obtaining an inspection,I agree to remove cmlt h....door air ach umim nts as dcOned by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes 'No I have read the hors rdeusmamrials requirements undel Chapter 6.95 ofOm Califon hire Health&Safety Code.Sections 255(15.25533 and 25534.1 undoomnd that a me Wilding Joel not In or ow a anent,Na it is my rtapomihility to m,dl'Sy the a'eupant of Ne requiromenT Must tomet poor%,ssuanceoraccruncateor Signature of Applicant Date apaner o s All roof coverings to be Class"B" or better C,n,aoh,oi.tt tgam Dam CWY OF CUPERTINO CITY OF PERMIT APPLICATION FORM D 3 ° 71 Z 3 0 •CUPEVINO APN # _ U Date: �13I/o3. Building Address: Mailing Address (if different from building address): �/J. f0 t'3 Rl wrb Or. Owner's Name Xlao ne Contractor: 78 D 1•` GL@r�se Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: Bld ❑ Elect ❑ Plumb ❑ Mech ❑ F Job Description: ` Residential ❑ �� lomme ial Sq.Ft. Floor Area: $/Sq.F : Cost of Project: Occupancy Group: r Type of Construction: Please check this box ' he r ' s 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> 100K 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 BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING l of3 X67 i8 d? C«'Y OF CUPERTINO CUPE(iiTINO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS as 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 Repipe 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 cfm MECHANICAL BREMAIRHAN A/C Units<= 10,000 chn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL r, BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREWMAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Mise Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL 2 of 3 j CITY OF CUPERTINO COPITY E 0 �No PERMIT APPLICATION FORM Qua Fee ID Fee Description Fee Group 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 BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS 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 Temporary 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 Issuance PLUMBING PPLBG Plumbing ee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3 hC4 GA • i nip T�'•m y A vI) qq°I I- c, z3 �- •J t , dJ p C1 Vi CJ A 1 ter.. E� d C'. F �` o • LI