05090023 (2) CITY OF CUPERTINOgyvy�„�+�«co3
BUILDING DIVISION PERMIT .CON=TRA.CTORINFUI2MATIrON.
BUILDING ADDRESS: ABLE,' SEPTIC' PERMIT NOO 509 OO23
iTIRO r)R
NER'S NAME: PERMIT ISSUE DATE
OW
LYNN CHING 520 REED S 09/06/2005
ONE: SANITARY NO. CONTROL NO.
(408) 377-9990
AR CHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTO PQ MECH
O
woo .LICENSED CONTRACTOR'S DECLARATION JobDescri hon
1 bunchy affirm that 1 sue licensed under previsions of Chapter 9(commencing p
with Scction]IXIII)a(Dlvielon3of the Budnw and Profs Lunn Crede and my Iwamoto
^� inrmlmmeandeRec� 2 �-� I f7fu' 7' EXTEND SEWER LATERAL, INSTALL C/O
Z Lice^.,C1au Use.N f� 1'� n
9� Dam ARCHll W use DECLARATION L` rpaf t), r7r (M ®
'� I undervnJ my pons Nall k used u public ATION LJI + xr {WVf jll
ct� a
50 Licensed Pmfcuianal
OWNER-BUILDER DECLARATION
.� I hereby affirm Nm 1 am exempt form the Contractor's Ucenw law for the SEP O�
00 following reason.(Suction 703 L5.Business and Professions Cade:Any city of county t7 (' / 2n®'
x$_ which require•permit to emuuuet,atm,imprew,demolish,or.,hu,any suuctwe
MN to
3 5 O O
2 poor its issuance.aruNims we applicant for lash pumit he file a signed statement
Net k is licensed renowned to the provisions of the Camrector's License law(CMpm 9 Sq.Ft,Floor Area ({ Valuation
$ (commencing with Section 7000)of Division 3 ofthe Business mod Profudoes Code)or }ff1
.. that k ts sumps tkre(rom and dm basis for the Alleged exemption.Any v1olNan of Bull ♦'f+ �I�
of
Section 7031.5 by any applicant fora permit nbje dm applkant w a ciAI penalty of IQCfa]OORRnC
not mom Nan Rw hundred dollar(SSOOk rt,.y��
❑I.ummarlheptopmy,mmyemploymwiN ge3uthe4wlecempeaudon,
wllldo the work and Nestmclum is nutinmMed moneml fonde(Sec.7044,Business Required Inspections
and Professions Code Tk Conuecmrt License Law dm e not apply m an owner of q p
propenywho buildtos improves thereon,andwho doessuchwarkhtmself or through his
own employer,provided that such Imprmemen4 the not Intended moRered forsala.If,
however,the building or improvement is mid within one year of completion,the owner-
builder wig home the burden of proving that k Nd wt build or Imprew for purpose of
ask.).
O 1,as owner of the property-am exclusively connecting with licensed comnnon in
construct%e Project(Sec.7044,Business and Professions Cade:)The Conowmrt U-
cenae law dm not apply in or,owner of propeny who build,or imporws themon.and
who concocts for such projects with a contrwtons)licensed pursuant m the Convectors
License Law.
❑lameaemptunder See .BkPCfmdds exon
Owner Date
WORKER'S COMPENSATION DECLARATION
I kreby ofllrm under penalty of perjury mm of the following declan0ons:
1 haw and will maintain a Cetifiam or Consent to self-insure for WmFmS Compere.
nation,as provided for by Smtion 3700 of the labor Code.for the po rormanm of the
work for which this permit is issued.
1 haw rod will maintain Workers Compensation Insurance,u required by Suction
3700of me Labor Code.for the performance of Na work for which this permit is issued.
My Warkgr;GampenmLtmn�m�suflnCC Canlef and PaIICy number ere:
Carrk. -� £ 1 x/'w�
Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
MI,semao need trot be completed If the permit I,Immm hundred dollars($100)
or leu.)
I ceNfy that In the performance of the work for which this Permit is issued.I shall not
employ any person in any mwnerso as to become subject to the Worlu ri Compemnion
Laws or Calirornla.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should
become subject in the Workers Compensation provisions of me Lahr Code,you most
OZ forthwith comply with such providaos or this permit shall k deemed rcwked.
zCONSTRUCTION LENDING AGENCY
F+ I hereby affirm mat there is a connnction writing agency for the performance of
PG> we work rue whim this parm4 4 issued(Sec.3097,Can,C.)
W0 Landers Name
L. Lenders Addrtu
U J 0 1 certify that I haw rad this application and tum Out the show inform W u t 4
pr corrM.l agree to comply with all city and county ordinances and sere laws nelating to
Wilding construction.and hereby unwell repwsentstives of this city in enter upon the
W ahme-mentioned property for inspection purposes
gL (We)agme to now.indemnify and keep l umleu the City of Cupertino against
fA liabilities,judgments.costs and expenses whim may in my way acrneagainst mid City
V 7 in emtuquemx of the{ran4ng of this Permit.
r'•t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCgREGULATIONS.
A\�r`YOQ0�`� �S Re-roofs
Signsture Applicm Oecmr Dam
H OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m futum Wilding oceupantstore or handle hanNoul mammal
as defined by the Cupertino Muni'PH Code.Chapter 9.11,and der Health and Safety
ole.Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes a
Will the applicant or future building occupant use equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
mit huamOas air conmene,u defined by me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I hoc mad the hmaNm
nusamrlats mquimmems under Chspmr695 Orme Califor.
nia Hcaftt SafmyCedc,Smiions35505,35533 and 25534.1 understand matifthe building
does t curtnn I haw•tenant,that it 4 my rmpmonifity m notify the Oceupam or the
ruqulrt wlllha. bus I 'ormluuammoraCerdficate ccup,�gy.,, Signature of Applicant Date
owner ar wren .=d ag �D,m`�- All roof coverings to be Class"B"or better
i
V Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building -De artment
JOB ADDRESS: PERMIT#
0s(p
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: L�F— G Rom FAX #
I am not using any subcontractors:
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 LE uADEPailW O
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Co tractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
ICUPEkTINO PERMIT APPLICATION FORM
APN#\,,35 05
J c DZ Date: _0_05
Building Address:
1054 SAA t-E,gnloR7i
Owner's Name: t—r �lrJ� 6 r ' -.I Phone#:
Contractor: . Phone: License#:
IAK ��JoFRl� ,,J,,D Loi 3�7 9" SP1 4TS
Contact:n 1 ,n�� Phone: _ 2j _ psl Cupertino Business License#:
F 0 (0
BuildingPermitInfo:
BldgL/ Elect ❑ Plumb ❑
Job Description:
ELJ-- P� U/v
�Ct�� S�u✓ER v°rt��t-, I�ST�Y t�
Residential Commercial ❑
Cost of Project: 3rS�
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 Repipe of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING