06040080 (2)A
CITY OF CUPERTINO
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BUIDDING DIVISION PERMITdCONTRAC�TOR
INFORMATION,
BUILDING ADDRESS:
PERMIT NO. 06040080
OWNER'S NAME:
PERNUT ISSUE DATE
OH NAM
NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUeMB MECH
0 [ 0
LICENSED CONTRACTORS DECLARATION
Job Description
I kreby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section](0(f.f Division 3 of th. Business and Proposal.. Code, and my license is
imfull force nderc«
TEMP POWER NEW HOUSE CONSTRUCTION
License Class Lk. g `/
77
Dale Continental
ARCHITECTS DECLARATION
canJ my plans aM1all k used asss public mcnrN
I undrsl pu
Q
(/
LkenttJ Pndusional
OWNER-BUILDER DECLARATION
I hereby aIErm that I am uempt from the Canuacmra License Law for the
/
following moon. (Section 1(D 1.5. Business and Professions Cade: Any city or county
which lelulrea a Permit to construct, alter. improve. dcamlish, or repair my aWCWm
o 1
prior it)its issuance, also mQuhor lk applicant forsuch permit to III ... i,ruds niter(
Contractor's LixnicLaw chapter 9
Sq. Ft. Floor Area
valuation
that he is licensed purmanttoNeprovisions ofthe
(commencing with Seeu0n 1000) of Division 3 of lk Business and Profusions Code)or
that k 0 exempt thurefrom and the basis for the alleged rrmption. Any violation of
TR&T Q Q
Occupancy Type
Section 1031.5 by any applicant for a permit aubjccu Nc applicant 10 A civil penalty of
not mom Nan fins hundred dollars ($500).
❑ I.uowncr oftk pmprty.rmy employees with vagunsJe'v role compensation,
Required Inspections
will dO Ne work and the smrcturt u not kmMed or oRered fauele (Stt. t0a4, Business
and Professions Code: The Conmcrors Licenm Law dors nos apply In an owner of
property who builds w improwa thcroon, and who does s uch workhimself or through his
dudsale.R,
own..dicc ere
dcraBered
sold within one year of c pm names,
t
pavemimprowm within
builder. the Wildingor n
prove for
builder will haw the burden of proving Nal k did rot build r improve for putyose of
ath of Proving
sale.).
❑ I, as Owner of the progeny, am eatelusively contracting with Ikuued conuacbrs m
consumer one project (Sec. 1044. Business and ProGstlm s Cade:) The Comeartm's Li-
cense Taw data not apply m in awnr of property who builds or improves themon, and,
,
who contracts for such projects with a conuaclor(s) licensed pursuant m the Contractor's
License Law.
❑ Iamuemptundcr See .BhIscrm Numam.
Owner Date
WORKER'S COMPENSATION DECLARATION
1 bereby affirm noun, pevity of perjury. of the following declarations:
10
1 ham and will maintain a Certi0um of Comcat In self-Induro far Warkee's Compen.
mdmi, as provided far by Section 3100 of the lobar Cade, far dm perPomunx of the
wore for which this Permit is issued.
❑ 1 haw and will mumaln Works, Compensation Ins ., u myvimd by Section
3100 of Ne labor Cod., for Ne perfarmace of Ne work for which Nis Permit is issued.
My Workers Compensation Insurance i.r and Paliry number. am:
Carver. f u Nd' Paliry No.: l4G% 8 �'��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
s
(This section need ill k completed if de permit I$ faream hunNradduilan ($100)
nr less.)
I certify dint in die perfarmanee of the work for which this permit is issued, l shall not
employ anyperson in any mdance" az b kcome subject to dm Workers'Compensation
,
laws of California. Date
Applicant
NOTICE TO APPIUCANT: If, after making Nu Cenifcae, of Exemption, you should
kcome subjoct m to Workrh Compcnsadon provisions of dm Labor Code, you mesa
foMwith comply with such provisions m Nu permit shall k domed ranted.
CONSBUCTIONLENDING AGENCY
1hcmbyaffirm them isacd(Soe.3 leading agrey far Ne perfurmeme of
a theLe mark for which Nis permit u issued (Sec. J091, Civ. C.)
Pe
jL<nden Nam.
,
l<naers Aea¢ss
I certify Nat I have read this application and rude Nat the above information b
corms I agro In empty with all city and county on inances and state laws rotating le
Wilding construction. and hereby autharin represenmirss of this city m cnmr upon tic
a above-mentioned property for inspection purposes.
(we) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilities, dgmenu. case an desperucswhichmayin anyway Iteme againstfatd City
r in <a uenee a( Ne granting of Nis permit.
APPL UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
(�'/ C/ �)
Issued by: Date
SOU REGULATI
1
Re -roofs
Type of Roof
Sigwu of AppI, manor Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future wilding IX.upantatom or handle h,oudOus material
as defined by the Cupertino Municipal Code. Chapter 9.13, and dm Heald and Safely
Cad.. Section2553y(a)?
❑Yes No
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
g P g
west me appkanl ar mwm knamg accapam use cympmeat or devices moron
emit havardnes air contaminants ai dcfincd by the Bay Arta Air Quality Management
all new materials for inspection.
Disuin?
❑Yu No
1 have mad Ne harand. materials mquincim. under Chapter G95 of the Colifor.
nu Hull ASsfelyCodc. Sections 25505.25533 eld 25534.1 eucnund Nat if Ne Wilding
docs at ndy naw a ¢nano az it i my responsibility m notify de occupant of the
mg0inc �whichnauslhmct darn, rwE Readof«capaacy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
g
nate
Own r w i Namctl agcm pans � �
ti
CITY OF
jjjf.UPERTIN0
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building De artment
JOB ADDRESS:
ct1 tn-e
PERMIT #
060 o o t- O
O R'S NAME:
PHONE # 2-5--736 9-3
GENERAL CONTRACTOR:
FAX # 92 -- 36z
I am not using any subcontractors: :: -- 04- _ i 4 —0
��7--SigAakue Date
Please check applicable subcontractors and complete the following information:
.,6!Wn'er/—Cb4trAtor Signature
Date
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
Til
.,6!Wn'er/—Cb4trAtor Signature
Date
CITY OF CUPERTINO
em 1 of 1 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Elk: Lot:
APN ........: 37514020.00
DATE ISSUED.......: 04/14/2006
RECEIPT #.........: 34006
REFERENCE ID # ...: 06040080
SITE ADDRESS .....: 18945 TILSON AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: OH, NAM
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: CHUANG XING CONSTR I
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
OPERATOR: bethe
COPY # : 3
&E
ID
______ _____________
UNIT
QUANTITY
__________
AMOUNT
__________
PD -TO -DT
THIS REC
NEW BAL
BTEMP FLAT
RATE
1.00
62.10
__________
0.00
__________
62.10
__________
0.00
BUSLIC FLAT
RATE
1.00
105.00
0.00
105.00
0.00
EPERMITFEE FLAT
RATE
1.00
38.37
__________
0.00
38.37
0.00
TOTAL PERMIT
205.47
__________
0.00
__________
205.47
----------
0.00
METHOD OF PAYMENT AMOUNT
_________________ ____________
CHECK 205.47
TOTAL RECEIPT 205.47
VOICE ID DESCRIPTION
103 UFER
r1
U
NUMBER
------------------
2522
VOICE ID DESCRIPTION
304 ROUGH ELECTRICAL
r—
*CITY OF
CUPERTINO
CITY OF CUPERTINO
EMP PO ER OW400W
PERMIT APPLICATION FORM
APN #
0 5-/ - W -D
Date:
1X`45
Building Address:
Owner's Name:
Phone #:
iq-0.y �3L!
-89ZZ
Contractor:
Ph ne:
License #:
C nM kn
e &1c ) k( ?/®— i
%7�� Z
Contact: 6 a
Phone:
Cupertino Business License #:
Vrl Wo
Building Permit Into:
Elect
{
BtcSeY/wlf�e-
Job Description:
Residential
Commercial ❑
Cost of Project:
500, m -J
11
Qty. if
Applicable Fee ID
Fee Description
Fee Grrnun
/ BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING