08100008CITY OF CUPERTINO
CONTI2ACQIt
BUILDING DIVISION PERMIT
BUIL.DINGA 06ESS:
lO1bU STERN AVE
PRINCIPLE ROOFING &
PERMTTNO. .
08100008
OWNER'S NAME:
PERMIT ISSUE DATE
NANCY HUNG & DERECK LOI
10160 STERN AVE
10/02/2008
NE:
SANITARY NO, CONTROL NO.
(408) 898-7298
ARCHTIEC (ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I Job Description
P
1 beehy a(Brm lhv 1 me diamond enter Pmvidwn of Chapter 9 (co mere ng
wit Section 70(X1) of Division 3 of use Business and Pmfessior Code. ant my license is
TEMP POWER FOR NEW SFDWL
in full force ant cffe L
License Clm Lac. M
.
Dam. Contractor
ARCHrTECiS DECLARATION
1 undersand my plans shsil be used as public meords
Licensed professional
OWNER -BUILDER DECLARATION
1 hereby affirm Nal I em exempt from Nc Commur /s License Law for dm
following meson. (Suction 703 1.5, Business and Prefemiom Cade: Any city at county
which minima a permit to ewm mus, slier, improv. demolish. or ¢pair my structure.
prior is issmm.also mquims IN applicant for such permit to file a signed suement
U.. Law 9
Sq. Ft. Floor Area$200
Valuation
tat he islimmed pursuant 19 dm Provisions of dm Contractor's (Chapter
(commencing wit Suction 7000) of Division 3 of do, Business and Prefesninns Cade or
to M is exempt thearfmm and to basis for to alleged exemption. Any violation of
3 7 512 0 0 6 Number
Occupancy Type
Schon 7031.5 by any sppliant fora permit mbjccu Ne applicant to a civil penalty offf
not come Nu fiw hundred dollars (M).
.
1, ss owner of the property wary employcms with wages as their sole compenartim.
Required Inspections
will do the workand mhommmdrt In net Intended or offered foomic (Sec. 7041, Businw
and Pmfesslaa Coda: The ContracmYs Llcenm Law dors not apply to an Damn of
property who builds or i m pmvn thereon. and who das such work himself or Ouough his
arson employees. provided that such tmpmmmem s art not intended or offered formic. If.
however, IN building Or imp om nu m is sold within.. year of complatian, Ne owner-
,
builder will have use burden of proving Nal be did mo build or impmm for propose of
ark.)..'
0 1. as owner of de property, am exclusively conducting wit licensed mnduetws as
commuct to project (Sec. 7044. Business and Prefessimm Code:) 7Le Contractors U.
cense Law docs not apply in an owner of property who Wilds or impro es lhamon. and,
who contracts for such projects with a comae r(s) licensed punuanl to the Contrsemrs
Liana Law.
S , B B P C for this on
❑Ives exempt und�erLx w
Owner V ai`� Duca 1 b/T
KERS COMPENSATION DECLARATION
1 hereby drum under panslny of perjury NO of i m following declvalions:
1 ham and will mdnain •Confute of Common to self -insure for Wminces Com sm-
'me. a pmA&d for by Seaton 3700 of IN Labor Code. for to performance of the
work for which Nis permit is Issued.
1 haw and will maintain Workefs Compensation Insurance, as regained by Sation
37(10 ofte Labor Code, for the performance ofte work fw which this permit is iniad.
'
My Worts/s Compenmdon Instance carrier sM Policy number arc:
Cartier: Palmy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fTidesection need Out Ncampleed ifrobe permit is forone hundred dollars(S100)
or lest)
I certify that in the perforron. of the work for which Nis permit u issued. l shill am
employ any person in my mTr as as b ba`Om .ecl�0/dC We do"
nbI
Lama of California. Dam ^ I /l/ c�a'I i
Applicant Vy
NOTICE TO APPLICANT: If, after ma�ung this Cenifmcam of Exemption, you mould
become subject in IN Wasters Compensation pmvisions of the labor Code, you must
' forthwith comply wit such prmidom or Nis permit shall be deemed mdwkad.
LENDINGAOENCY
'
1 hereby dua ft. is 3 lending agcnry for to performance of
M. Ope there is •
' ch Wood (Sec.
to work fur which Nis permit is issad (Sec. 7097, Cie CJ
'
LendeYs Namc
,
e Lendefs Adder
1 exactly that I Mm read Nis application and stem to the sham informed.. is
• cortecL 1 agree b comply wit sit city and county orlim nces end sum laws relating to
building construction. and hereby auNams, mpmxnudma of this city to cru upon the
J .how -mentioned property for inspection purport
(We) agree to mw. indemnify and kap humless six City of Cupertino against
labilite, judgments. costs and npeasn which may in any way scram, agaiml mid City
in commquence of to panting of tis North.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:Date
-
SOURCE ULATIONS.
to r8
Re -roofs
/
Type of Roof
Signature of Applicamu'Conuactor Dem
HAZARDOUS MATERIALS DISCLOSURE
Will Ne appliantor future building oaupammore at handle herardods material
_
as dellnW by Na Cupertino Municipal Code, Chapter 9.11. and to Healt and Safety
Code. Section 25532(a)7
All roofs shall be inspected nor to an roofing material beim installed.Dyes
PNa
I If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use oqutp rdmL or devicas.which
i huzomus air ==I"na a food by use Bay Am. Air Oddity Management
all new materials for inspection.
cm7
❑ Yes u
I ham read Ne haramdaus materials requimcmrrs under Chaper 6.95 ofthe Culler.
NaHaINhSafayCode, Smcdons15505.25533ant25534.1dnderstandt ifde IedEing
docs not curmndy Mw a mnanl tv It u my rnporibility m witty IN occupant of Na
rcyuircmcna whigmmcanecmet poor m iaawncc ofa Certificate ofo�upem7/
Signature of Applicant Date
td b
All roof coverings to be Class '%¢" or better
D
owner or auNorimd again Dam
• 4 ITEMS OF 4
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37512006.00
DATE ISSUED.......: 10/02/2008
RECEIPT #.........: BS000006261
REFERENCE ID # ...: 08100008
SITE ADDRESS .....: 10160 STERN AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA-.......
OWNER .............. NANCY HUNG & DERECK LOI
ADDRESS ..........: 10160 STERN AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: DERECK LOI
CONTRACTOR .......: DERECK LOI LIC # 27564
COMPANY ..........: PRINCIPLE ROOFING &
ADDRESS ..........: 10160 STERN AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........: (408) 898-7298
OPERATOR: patg
COPY # : 1
• FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
1BSEISMICR
VALUATION
200.00
0.50
0.00
0.50
0.00
1EPERMITFE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
1ERT<200
UNITS
1.00
40.79
0.00
40.79
0.00
1TRAVDOC
FLAT RATE
1.00
40.79
0.00
40.79
0.00
TOTAL PERMIT
122.87
0.00
122.87
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT
AMOUNT .
---------------
122.87
---------------
122.87
VOICE ID DESCRIPTION
------- ------------------------
402 TEMPORARY POWER
s
REFERENCE NUMBER
--------------------
MC
VOICE ID DESCRIPTION
CITY OF
qfUPEkTINO
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
lGl6o Sfi� ��C—
PERMIT #
U�/
OWNER'S NAME: Nati NP?V�r oc-nEe-ic-L--'
PHONE #
GENERAL CONTRACTOR: 2w nro
FAX #
I am not using any subcontractors: (a C G
Signature Date
Please check applicable subcontractors and complete the following information:
•
Owner/ Contractor Signa e
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
Tile
•
Owner/ Contractor Signa e
Date
n
r
L
v1/0 o o(-)
CITY OF CUPERTINO
' TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
APN # _
Date:
Building Address: 1 o I L O 9+GVL n/ AJ i—
Fee Group
�r(J� Ff1VU�-G� Fr \,f
Owner's Name:
Phone #:
N'a- jCcf 1 to ,6r- /
G4fh1) Z3 �l8 — wl8
Contractor:
Phone #:
Res. Temp Power<200
Amps
Z,") i ,� i; - 7-ze,?
Fax #:
Contact:
Phone #: C
E
Contractor License #: t C 3 1
IEPERMITFE
Cupertino Business License #:
E
Job Description:
IELCPLNCK
Electric Plan Check
Residential Commercial ❑
Valuation (cost of project):
Type of Construction: N/A
1BSEISMICR
lv A -
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1ERT>1K
Res. Temp Power >1K
Amps
E
1REAP14
/
IERT<200
Res. Temp Power<200
Amps
E
IERT2001K
Res. Temp Power 200-1K
Amps
E
/
IEPERMITFE
Electric Permit Issuance
E
IELCPLNCK
Electric Plan Check
E
1BSEISMICR
Seismic Residential
B
1TRAVDOC
Travel & Documentation
Fee
B
aOFoitua
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1BSEISMICO
Seismic Commercial
B
10EAP14
IECT<200
Commercial Temp Power
<200 Amps
E
1ECT>1K
Commercial Temp Power
>1K Amps
E
1 ECT2001 K
Commercial Temp Power
100-1KAm s
E
r
1TRAVDOC
Travel & Documentation
Fee
B
1BUSLIC
Business License
B
0
Revised 6/16/08 •
0