06060219 (2) BUILDING DIVISIONpRMIT ` CONTRACTQR INpURMATTON
BUILDINGADDRESS: PERMITNO06060219
147 TWIG LANE 1711,1-7
ERS NAME: M PMC PERM[[LQUE DAM
CHAU TRAM T V�gJ
PHONE:
SANITARY NO. CONTROL NO.
I3 f1
V
ARC HITECf/ENGINEER: w ! r 1 RBUBDING PERMrf INFO
BLDG EI.EtI' a PLUMB MECH
opo LICENSED CONTRACTOR'S DECLARATION lob Descrl 1 LUV
4 1 hammy affirm that 1 am licenced undcc provisions of Chapter 9(commencing
ith Section 70110)of Division 3 of Ne Bonn.and Professions Code,and my license is
^oNin full to=and effect- TEMPORARY POWER POLE pyy 'y1 Ay q1 yip�ftt
License Class Ommu �i)'7 t� tl N
2- Dam Con DELL ��[[..JJ YM IL/SJfLt:.//J`u�
7W ARCHITECTS DECLARATION
e< 1 understand my plans shall W used as public records
D-u
g C y Licensed Professional
S OWNER-BUILDER DECLARATION
q 1 Wmhy affirm Nm I am exempt from the Conlraaors License Law for Me
p o following memo.(S dmr 7131.5.Business and Profexeme Code:Any city or county
which requires a Permit to contra L aher,impur e,dcmolish.at repair any stnmure $183
prior a its issuance,also requires the applicant far such permit to file a signed statement
x Nat heisliceucdpursusnttoda,pmvisiomti
of ls
e .(Chapm9 Sq.Ft.Floor Area Valuation
xl-Q (commencing with Section 7000)of Division 3 of Ne Business and Professions Code)or
Q that he is exempt therefrom and the buts for the alleged exemption.Any violation of
Section 70313 by airy applicant for a permit subjects the applicant to a civil penalty of -5 ATN144kltaro 0 Occupancy Type
am mart Nan fiw hundred capon($500).
❑1,u owner of Ne pmpmy,or my moplo a with wages u Nab sole compensation,
will do the wohaM the suactum is ao,uumdednraffered forsem(Ses.7044.Business Required Inspections
and Profess ons Code:M Conoanofdoes dent License Law donot apply m an awncr of q p
property who builds or improves Neman,and who does such work himself or through his
own employees,provided Nat such improsemenu tie not intended oraReread for sale.If.
however.Ne building or improvement is sold within one year of completion.the owner-
buildcr will have the b rdere of Proving Nat W did not build or impose for purpose of
ale.).
Yu owner of the property am amind ely...urmting with Boned commemrs e
wct the pmjm(Sec.7044.Business and Professions Cade:)The Conmemor's Li.
cense law does not apply to an owner of property who Wilds or imprones Merano,and.
who concocts for such Mimics with a conusmor(s)Handed pursuant a the Cm araceYs
Lica se law.
❑Imnac to Sca � B&PClar a
Data
WORK MPENSATION DECLARATION
I hereby allure under penalty of pegmy arc of the following deigning,
❑I have and will far b i SeCmtifiase of Me Labor Code.fure far Wmtrfs Compen-
workf r provideditMi fm a Section 3]00 of the Labor Code.for dm Performance of dm
wade for which Nis permit is issued.
❑I have and will maintain WorkcYs Compensation Insurance,as requirod by section
37M m'NC Labor Code.far Ne pcdormantt of the work for which Otis permit is issued
My Works,CompeesaGan Wrier as artier and Policy numWr are: '
Cartier: Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thu smion need ret W completed if dr Permit is forone,hundred doll,,(SIM)
or leas)
1 certify Net in the Performance of the work for which this Permit is issued,I shill not
employ any Pusan in any manner so as in
_bsraL 7W kftW Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cmdricam of Exemption,you aboard
become subject in Ne Worecr's Compensation provisions of in,Labor Code,you mus,
.J O fmdawith comply with such provisions m Nu panni,shall W domed hawaked.
z CONSTRUCTION LENDING AGENCY
[-a I hereby alarm Nat them is aconswcted lending agency far the perfurmance of
7. Ne work for which Nis Permit is Luued(Sec.3097,Civ,C.)
6W. Q Isnmes Name
7 z Lenders Address
U0 I araify Nat I have read this application nM new Nat Ne above information is
U.F correct.I agree to comply with all city and county ordinances and sum laws muting to
0 Wilding construction,and hereby surname mpmxcnutirs of this city to cmcr upon the
ahovc-mcmioncd property for inspection phichmn
H y (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities, cnta.cosn and expensumit. may in anyway accrue againn aid City
U z A ca vena f Ne granting of Nu permit. /^ /
'-' SO ANT NDER DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ER LA S.
h LL
Re-roofs c—Z—
Signuu¢afAppli ontrxes Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne appliaat or form Wilding occu,numsem orhandla hazardous material
defined by the Captain.Municipal Code.Chapter 9.12,and tie Health and Safety
.section 25532(e?
C3 Yes All roofs shall be inspected prior to any roofing material being installed.
�o
Will the applicant or future Wilding aoupanl use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as derincd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ro
I deme dm Ward.otgar.Is mWimmenu underChaprer 6.95 eft Califon
via Hreib sfe Cnde,Sections 25505.25533g,425534.Iundemund Nxtifum Wilding
docs at tine y ave are t u my responsibility a ramify the omupant of the
.quirt ata n must be prier,ousarmcofacerti0ate rasp lyre D Signature of Applicant Date
Owner ofauthor;xedagent �D. All roof coverings to be Class "B"or better
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37508019.00
DATE ISSUED. . . . . . . : 06/26/2006
RECEIPT #. . . . . . . . . : 35018
REFERENCE ID # . . . : 06060219
SITE ADDRESS . . . . . : 19147 TWIG LANE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . . -
OWNER . . . . . . . . . . . . : CHAU IRAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CHAU TRAN ,
CONTRACTOR . . . . . . . : LIC # -,
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
• TELEPHONE . . . . . . . . :
FEE ID UNIT 'QUANTITY AMOUNT .PD-TO-DT THIS REC NEW HAL ,
__________ _____________ __________ __________ __________ __________ __________
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
_________________ ------------ _-______-________-
OTHER 100.47 MASTERCARD
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
gCITY OF Fax(408) 777-3333
PEkTINO
ByRding Department
JOB ADDRESS: I o l�—j PERMIT #
o6b101 �{3
OWNER'S NAME: PHONE # $'10 — -3
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: C 0 6
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
• Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
T.ErViP .POWER >�G
DSD
CUPEkT]NO PERMIT APPLICATION FORM �
APN# 75 ;T 6)/m
Building Address:
Owner's Name: Phone #:
C-ft4 u Tko �-NI ,siv-q 0-3 4/6 3
Contractor: Q I Phone: License #:
CWCho-ns-Fru d-���. 313 - y I o1 55 77 g/
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect
Job Description:
Residential Comme tial ❑
Cost of Project:
Qty. if
Applicable Fee E) Fee Description Fee Group
/ BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING