05070150 (2) CITY OF CUPERTINO
-. BUILDING DIVISION ONTRACOtINORMA00 .- z.r
BUILDING ADDRESS: DAREN SHU PERMIT NOO 5070150
NEWS NAME: PERMIT ISSUE DATE
D
lipONE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BO EO PLO MFCH
O
woo LICENSED CONTRACTOR'S DECLARATION Job Description
4 u I hereby affront that l am Iicomed under provision of Chapter 9(Commencing
with Section 7000)of Division 3 of On Business and Professions Code.arm my liceme is
+n„ bOsErormandefrea INSTALLING TEMPORARY POWER POLE
jJ? License Class Lic.0
= Date Contractor
ARCHITECTS DECLARATION
I underaund my plan that W used as public remods
�yU
se.Gr' Licensed Profcsslonel
i5 OWNER-BUILDER DECLARATION
i I I hereby affirm that 1 am eacmpt from dee Contramora License law(or the
E p O following mason.(Station 703 1.5,Bus nus and professions Cade:Any city at county
a$ which requires a permit to Consumer,alter,hoprove,demolish.or repair any structure $1200
-a L' prior no its issuance.also requires tW applicant rorsuch Permit o file asigned moment
i<
Chat he is licensed pursuant to the provisions of ft Comommes License Law(Chapter 9 Sq.Ft. Floor Area Valuation
E t-� (commencing with Sued.70DO)of Division Sof the Busincumd Profcaaiam Code)or
that he is eampt IMre(mm and the bub for the alleged!exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects We appliC.Lto•civil Pemlty of Occupancy Type
not mom than five hundred dollars(S50D).
Q L u owner of die property,Or my employcu with wages u dao sole compeneadon,
will do the work and theswcwrc hnotimmsided mattered I...le(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's Liceose Law does trot apply a e ns an owner of q p
property who bulids tar improver thereon,and who doesanch work h Imsel f e r through his
own employees,provided that such improvements m not Intended"offered forsab.IL
however,the building or improvement is sold within one you of completion,the owner
builder will haw the burden of proving that he did not Wild or Improve for purpose of
salaj.
1,as Owner of the property,am exclusively contracting with licensed conuacmrs to
C street the project(Sec.7044,Business and Professions Cade:)The Contractor's Li.
come Law dao not apply to an owner of property who Wilde or improves thereon,and
who contracts for such projects with a contncusi licensed pursuant to the Commerce, • .
Licence La . ..
❑lamer S.C.o .B&PCT thhm
mer
Data -.
P ,i 4DECLARATION'
1 hereby affirm under penalty of perjury Om of the following decorations:
1 have and will maintain a Certificate of Consent to sel6lnsum for Worker's Compete
Winn,as provided for by Section 3700 of the Labor Code,for the performance of the.
work for which this Permit is issued.
❑I have and will maintain Workers Compemarlan Insurance.as required by Section
37M of the Labor Code.for the performance of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number are;
Carrier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thbsection nead not be completed Iffl a perok Isforane hundred dollars(SIM)
or lea)
I Mildly thss in the performance of the work for which his permit is issued.I shall not
employ any person In any manner an as in become anbjtaI an the Worsens'Compensation
Laws of CaI tom, Date
APlitt.,
NOTICE TO APP ing Nb Certificate
become subject in the Waher'a Compensation provisions of the Lahm Code,you mus
,JO forthwith comply with such Provisiom or this permit shall be dcemW remked,
z tiCONSTRUCTION LENDING AGENCY
(-t I hereby aRrm that them is.Coutrucims lending agenry,for the perfarmanei
C4> the work for which this permit is issmd(Sce.3097,Cb,C.)
GQ Lenders Name
r1. z Lenders Address
U O 1 mildly that I have read this appliession and sum des the above Information b
ly Corea 1 agree to Comply with W city and county ordinances and mm lawn muting eo
Q Wilding construction,and hereby audmme representatives of this city to enter upon the
W above-ommIa d!property for impecdem purposes.
G (We)agree to now.indemnify and keep hamless she City Of CuPonino Against
cn liabilities,judgments.cats and expemes which may in any way sone Against said City
U z in consequence of the Sunni of this permit.
s'w APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON P INT Issued by: Date 71�z,r;.S'
SOU ULATTO r'7 0
I Re-roofs
Signs I' i Dam
AZARD US MATERIALS DISCLOSURE Type of Roof
01 the applicant or fumm building occupant time or handle haardous material
a defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Section 25532(4)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Wilt the applicant or future building Occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haardous air contaminants as dclimcd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea ONO
I have mail the haardnus materials requirements under Chapter 6.95 of the Cali(or•
.is limith&Safety Cade,Sci 25505,25533 and 25534.1 undersand that If thO Wilding
does not urentlyhoe a mnanL that It Is my naponsihllity m tmdi'y thC accuyp�mt of thc
requiremc is which must W met eo lssuance9 M4,11 /ora certificateo mVU Signature of Applicant Date
Owner tar. a horir w m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
aCOF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMTr # S—d
loVgq sceidIG Isu/b_
O R'S N PHONE # V O
GENERAL CONTRA OR FAX# a 2
I am not using any subcontractors:
t e 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ir
ontractor Signature Date
,t f
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kiereaw
COPY # 2
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35706002.00
DATE ISSUED. . . . . . . : 07/25/2005
RECEIPT #. . . . . . . . . : 30505
REFERENCE ID # . . . : 05070150
SITE ADDRESS . . . . . : 10489 SCENIC BLVD.
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DAREN SHU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DLCM HOMES
CONTRACTOR . . . . . . . : LIC # -OWNER-
COMPANY . . . . : . . . . . : DAREN SHU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE .
EE 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
----------------- ------------ -----------_____--
CHECK 100.47 1121
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
1
�- CITY OF CUPERTINO
05'1-01SDd` TEMP POWER
�cuPERTwo PERMIT APPLICATION FORM
APN# Date:
3� -o �0a2 � 72 � /0 - - -
Buil ding Addres� g S (G �3/��r/n
Owner's Namp': S, Y Phone: �(�D �
Contractor: Phone: License#:
Ow rJ Ef2
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑ //J 5`]4U-1 A/, -r6l oX*K- pdW�t�
Job Description:
S
Residential Commercial ❑
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