07010158 -7777777777
CITY OF CUPERTINO
BUIL'D1NG DIVISION PERMIT
1�'T AG7�C?R IN w. .J1. MAN '-_
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: TE
LICHUAN PAN 1447 HPMPTON DR. 01/25/2007
TONE: SANITARY NO. CONTROL NO.
(408) 6E6-5298
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p LICENSED CONTRACTOR'S DECLARATION Job Description
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
=i w with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE 10 DAMP WITH NEW 10 0 AMP PANEL
n a a in full force and effect. �,_
j
Z_ License Class _ Lic.8 ;:2-
�—
p Date conARCHITECT'S DECLARATION
ed< I understand my plans shall be used as public records
�yU
u.H Licensed Professional
n y; OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
< 9 which requires a permit to construct.alter,improve,demolish,or repair any structure
n Z y prior to issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
xF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $150
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 Number Occupancy Type
not more than five hundred dollars($500). 35617047 .
❑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 does not apply to an owner of q
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-
er will have the burden of proving that he did not build or improve for purpose of
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
L' Law.Law.
7 exempt under Sec. ,B&P C for this reason
OTTTOwner. �i7 I — _ Date
WORKER'S C0MW,,NAAT1ON DECLARATION
I 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.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 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: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or less.)
I certify that in the performance of the work fo ch hs ermit is issued,I shall not
employ any person in any manner se Vc c fibjRt t Workcrs'Compensation
Laws of California.Due
Applicant a 1�
NOTICE TO APPLICANT:If,after making this Certificate o xcmplion,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
F-h CA 1 hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
ALender's Name
.7 Lender's Address
U 0 1 certify that I have read this application and state that the above information is
h correct.f agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
G>~ (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
fJ z in consequence of the granting of this permit. Date —C)
►'t APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL� N-POIVT Issued b�:
SOURCE REGULATIONS1.7 '1
" u
Y ' Re-roof:
Signature of ApplicanNComractor Dare Type of Roof
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
cove,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ycs RrN. ,
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
C]Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate `o Signatury.-of Appl icant Date
or authorised agent ` All roof coverings to be Class"B"or better
Owner Dare
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
"UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: L.`G Gt c-��c �L PHONE # C 37 Z
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and com Clete 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
— c
Owner/Co tractor Signature Date
d CITY OF CUPERTINO S
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
_CPN# Date:
Building Address: ST Mailing Address (if different from building address):
& CIO Lw�fic �- vw C -N ? S- / `f
Owner's Name: Phone#:
Contractor: 4, Licpse #: g / /
Contact: Phone: 2--�� Cupertino Business License#:
Fax: v 2- 3 � 3 4
Building Permit Info: Ago Q-\ 44-P
oA�,
Bldg ❑ Elect L�' r� Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: S Occupancy Group: U w n
Type of Construction: Please check this box if the project is a
second-story addition: El
Project Size: Standard ❑ Large ❑ Mzjor ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Bol.er>500K to 1M Btu MECHANICAL
BBOILER4 Boilor> 1 M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Ccnstax-Resi/Mobile BUILDING
BELEC 1000 E:ec 600V<= l OOOA ELECTRICAL
BELEC1001 E1ec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD anergy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF (:UPERTINO
.
CITY OF
PERMIT APPLICATION FORM
CUPER,TINO
Quantity Fee ID Fee Description__ Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Th,:atrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD 3cb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC :Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Plannin ;LR Comme/Multi-Fam PLANNING
PLLONGRNGR Plannin ;Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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