05030030 (2)CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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DING ADDRESS:
1111 N` `5030030
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
'
BLDG ELECT PLUMB MECH
O O O O
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
P
I hereby affirm that 1 am licensed ceder provisions of (commencing
with Section 7011(1) of Division 7 of the Business and Professions Code. and my license is
Llco suclasosdcReu Lk.0
2 PROPERTY LINE CLEAN OUTS
Dam Comment,
ARCHITECTS DECLARATION
I undersand my plana shad be used a public records
Licensed Profeaomnl
OWNER -BUILDER DECLARATION
1 hereby M. Nm i em exempt from dm ConVuloYa Liceem Law for the
following moon. (Section 7031.5. Business and Profcaua Code: Any city or county
which ingot. a permh to emnwc, site, Improve, demallah, ar mpar my structure
prior m its issuance. also requires the applicant for such permit Ole asigood stsmmmn
that he la licensed to the of the Contnsears License (CheaterLaw 9
Sq. Ft. Floor Area
Valua ion
pursuant provisions
(commencing with Section 700M of Domains 3 of the Business ad Professions Cade) or
that he I. exwpt dmmOnm and the basis for the alteged exemption. Any violation of
3 G&IN150090 0
Occupancy Type
Section 7051.5 by any spplicaut fora permit subjects the epplWnt a a civil penalty of
not mom d m Bw hundred dollua (5500).
ownerofthe with vn{auNei(tele7W.B cation,
netor
Required Inspections
will do ounu
the Is tmountedntapplyinn..
teicense
thewon ands; he
namnw
dosed
Pr Code: The Conuamrt. Llceuo law don not apply if rs awwr of
and Contexuan, Law
q P
enywh bas sed who nimmlror Woagh his
pmpenywne Wlprovid mprovnch
messuchwork
Netsuchimpswidwi ase nnintendedmo@redIreask.If.
awnem. impr
ftbaprovided
buildvu,dm Wilding adds ovenom4 sold widid an[ yea(ofmmoveItstheowner-
builder will one um Wades of proving that he did oat build or improve (m purpose, of
sale.).
- /v
// ....
I. as Owner of dm pmpcny. am exclusively contracting with licensed eontncmn m
aT
the (Sec. 76th, Business and a Cadei The Convector's
onts,
rry who d
La docs not ts owner of pnopeny who Wilda improves Nommen and
cove Taw dna not apply
ra
for such projects mill. consranor(O licensed parsons m the Convanota
wbo. e
Late Law.
❑ 1 atn uemps under Sec. . B k P C for Nb mann
owner 1"�'f-�✓�l/ D,m 3/l
WO ER'S COMP ATION DECLARATION
I hereby affirm under peaty of perjury one of the following declamou:
I haw and will maintain a CertiOnm of Consent inselGinsum for Workers Compere
union. u provided fm by Section 5700 of the labor Cade. far that performance of date
rk for which at, permit is Wood.
1 have and will maintain Worker's Compensation Insurance, u required by Section
of the Labor Code, for the performance of sae work for which this Permit u issued.
y Worker's Compound" launwe carrier and Policy number are:
Mcr. Polity No.:
CERTIFICATE OF E(EMP ION FROM WORKERS'
COMPENSATION INSURANCE
CrIus action need not W completed if the Permit u Toro a hundred dollars ($100)
or dna.)
I cenify Not In the performance of the work for which this Permit is Issued. I shall not
employ any person in any mmwrm a at became subject to the Workers' Compensation
Ls,
Laws of Califoml . Dem
.e%r��
NOTICE TO APPLICA . If, after m g thls Cmudle a Of EumPtion, you should
become abject a time Worker's Compensation provision of sed labor Code, you muss
forthwith comply with such provision or this permit shall W dcomed mwked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a com action lending agency for the performance of
the work for which this permit is issued (Sec. 5097, Civ. C.)
Landces Name
�._.
lender's Addmss
I coolly that 1 have mad this applkauon ad tum that the .bow informants ls
eonam. l a&= a comply with all city ad county ordinances and mom [am miming m
building construction. and hereby muhodm repreaenoties of this city m enter upon Nc
above-mentioned Property far impecdan purports.
(We) agree to saw, indemnify ad keep ha(mless she City of Cupertino against
liabilities,judgments, tofu and expenses which may in my my we=agsiml sad City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIO /
Re -roofs
Type of Roof
✓�a/ > z-, 31 --lo
Si{suture of Appl mOCanRDO Dam
s
HAZARDOU ATERIALS DISCLOSURE
Will tim,pplinm or (alum building wcupmtuam or handle haaAow mamrisi
u de0wd by sae CupeNno Munapal Cade. Chapter 9.11. and the Hcalth ad Safety
code. Section 25531(.)7
Oyu XNO
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or dcviaa which
It havardous air contaminants a defined by the Bay Area Air Quality Management
all new materials for inspection. ,
isvictT
❑Yrs KN.
I hat mad the haardmomwdalsmquimmenmunder Chapmrd.95 of rite Califon.
nice Hulth & SaktyCodc,Sariau25505.25555 uu125534.1.kmad audde Wilding
time sus cuwndy have a mnan4 that II is my responsibility to madly the =up., of sae
requirements which man kand priorto Wean ora prarkite ofoccu ty.
Signature Df Applicant Date
3 DO 0
All roof coverings to be Class "B" or better
Owner
or authamc0 sent Dam
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CUPEkTINO
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CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
cl5S�o�30?)
APN #��v
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PLUMBING
Date:
.S—
Buildin Address:
sk
PLUMBING
Owner's Name:St
Ts e- to L{
w
BPFIXTURE
Phone #:
Contractor:
1', tn
BPWSVCS
hone:
License #:
Cont ct:
141\t4
Sewers
Phone: n ' /2
Cupertino Business License #:
Building Permit Info.
Bldg ❑ Elect
❑
Plumb
Business License
Job Description: ��1zJL/.)/'�
Residential
Commercial ❑
Cost of Project: vvv
Qty. if
Applicable Fee ID
Fee Descrintion
Fee C;rnnn
PPERMrTFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pb] . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING
I
a 1 of 1
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36212021.00
DATE ISSUED.......: 03/02/2005
RECEIPT #.........: 28778
REFERENCE ID # ...: 05030030
SITE ADDRESS .....: 883 SEPTEMBER DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: euem
COPY # : 3
OWNER ............: TSUE-YUAN HWANG/SHOUCHERU YEN
ADDRESS ..........:
CITY/STATE/ZIP .... ,
RECEIVED FROM ....: ANGEL HWANG
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
IRE ID
UNIT
______ _____________
QUANTITY
__________
AMOUNT
__________
PD -TO -DT
THIS REC
NEW SAL
PPERMITFEE FLAT RATE
1.00
__________
38.37
__________
0.00
__________
38.37
0.00
TOTAL PERMIT
__________ __________
38.37
__________
,0.00
----------
38.37
0.00
METHOD OF PAYMENT
_________________
AMOUNT
NUMBER
OTHER
____________
38.37
__-_______________
MASTERCARD
TOTAL RECEIPT
38.37
VOICE ID
DESCRIPTION
VOICE
ID
DESCRIPTION
106 SEWER
& WATER
202
UNDERFLOOR PLUMBING
301 ROUGH
PLUMBING
302
TUB & OR
SHOWER
502 FINAL
PLUMBING
ENERGY
506
GAS TEST
507 FINAL
PLUMBING