07010124 7---7777777777777
CITY OF CUPERTINO
BUILDING DIVISION PERMITr:QIiMx4TI�N.:
BUILDING ADDRESS: PERMIT NO.
10 1 2 2 "RE ET AVE EASTMAN- r PERMIT LSSUE DATE
OWNER'S NAME:
MAXINE CHIN 1418 DOL`GLAS ST 01/19/2007
SANITARY NO. CONTROL NO.
.ONE:
(408) 97] -9000
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION Job Description
V P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
=U with Section 7000)of Division 3 of the Business and Professions Code,and my license is REROOR- TEAR OFF, 20 SQUARES COMP, 2 SQUARE BUILT
a in full force and a ecu
iz LicenscClas e Lic.ft �� UP, 4/1:', PITCH, NO PLYWOOD, 270 LBS/SQUARE. CLASS
Fp Datc Contractor
f� ARCHITECTS DECLARATION
m< I understand my plans shall be used as public records
�W
U.r— Licensed Professional
n
0,
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K,$ which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
F_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $6037
nh (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 7 511 0 4�� .�L1bN Number Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law toes ROL apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sea B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's
r�m alio Insurance and Policy number am:
Carrier.ill P �. T—UkL!/L—Policy No.: 7517— AJ'7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z "' CONSTRUCTION LENDING AGENCY
[~a D4. 1 hereby affirm that there is a construction lending agency for the performance of _
py> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U C t certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
.J U building construction,and hereby authorize representatives of this city to enter upon the
G3•-i above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►'� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE R CATIONS.
9 2- Re-roofs
Signature plicanV nttactor Da T Of 1:OOf
H ARDOUS MA ALS DISCLOSURE Type
Will the appli or future buildi occupant store or handle hazardous material
az defined by the Cu vino Municipal Code,Chapter 9.12,and the Health and Safety
Code,section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or�U!rcbuilding occupant use equipment or devices which
If a roof s installed without first obtaining an inspection,I agree to remove -
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
D
1 have read the hazar ous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if thc building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements w must be met ri r to issuance of a Certificate of 0c panty. SlgnatUrE O Appli t Date
v 7- All roof co erings to be Class"B"or better
Owner or au nrcd age D
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`UPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # X) 111 " 9 000
GENERAL CONTRACTOR: FAX # o'� 9-71 7
I am not using any subcontractors:
Sid ature Date
Please check applicable subcontractors and com ►lete 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
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blh: Lot:
APN 37!,11040 .00
DATE ISSUED. . . . . . . : 01/'19/2007
RECEIPT #. . . . . . . . . : BS000000268
REFERENCE ID # . . . : 07010124
SITE ADDRESS . . . . . : 10:.22 BRET AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER MA::INE CHIN
ADDRESS . . . . . . . . . . : 10:_22 BRET AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : JAMES EASTMAN LIC # 22140
COMPANY . . . . . . . . . . : EASTMAN CONTRACTING, INC
ADDRESS . . . . . . . . . . : 14:-8 DOUGLAS ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95126
TELEPHONE . . . . . . . . : (408) 971-9000
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
BPERMFEE VALUATION 6, 037 . 00 137 .16 0. 00 137 .16 0. 00
BSEISMICRE VALUATION 6, 037 . 00 0.70 0. 00 0 .70 0. 00
BUSLIC FLAT RATE 1. 00 107 .00 0. 00 107 . 00 0. 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 244 . 86 0. 00 244 . 86 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 244 . 86 32240
---------------
TOTAL RECEIPT 244 . 86
r,14
CITY OF C:UPERTINO
` REF.00F
CUPEkTINO PERMIT APPLICATION FORM
APN# 315- 11--040 Date:
Building Address:
An .
Owner's Name: Phone :
a) n' CGiin %o 2- `�600
Contractor: License#: _
•�L2,SrVhGivt 2-�f? �' V✓�-der �U�] �nc . G.�?�D�"��
Contact: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed: (- 1
0( Built-Up Roof Built-Up roof
Asphalt Shingles ,? Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
N tuber of existing coveringsate— ❑ Provide I.C.B.O. Report#
To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read,Understand and Will Comply With Cur ertino's Tear Off Policy:
Job Description: -Tear CcliA r 2- H - G{-/( 2-
Residential
Residential Commercial ❑ R0 VVDod,
Fire Zone: Yes ❑ No [ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: 00.z me of Construction: Occupancy group:
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BPERMFEE E-Idg Permit Fees BUILDING
BENERGY 3nergy BUILDING
BSEISMICRE 30eismic Fee Res BUILDING
BSEISMICOM ,3eismic Commercial BUILDING
BPLANCHK Man Check Fee BUILDING
BUSLIC Business License BUILDING