08100206 CITY OF CUPERTINO �a�2��as •,/�x�r-
BUILDING DIVISION PERMIT kXA'./ TRAC"°TV1k��
BUILDING ADDRESS: PERMIT NO.
21044 HAZELBROOK DR JL CONSTRUCTION ENTERPRISE
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SA CONTROL NO,
ARCHITECT,ENGINEER: BUILDING PERMIT INFO
INSTALL NEW LIGHT FIXTURE BLDG ELECT PLUMB MECH
O O O O
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LICENSED CONfRACi'OR9DECLVtATON UNDERNEATH NEW DECK
wZ 1 bemby affirm Wr 1 sem licensed under provisions of Chapter 9(commencing lob Description
nen with Section 7")of Division 3 ofd.Business and Profnsium Codc,and my licensee
< in full force and effect
_ uewe an. Us.g .
L, Dam contremr,
ARCHITECTS DECLARATION
1 cauk numl my plans Nall W used as public...'a
I U
g C r Licensed professional
3
OWNER-BUILDER DECLARATION
to
y I hereby alarm that I an exempt from the Contractors license Law for the
ZOO following moron.(Section 7831.5,Bessiseu and Prefeuiuv Code:Any city or county
$ which requires a permit to censwcL alar,improve,dcmolkvh,or repair any structure
prior aits issuance.also requires the applicant forsuch permit to file a signed Ratemem
< ton lm is licensed purmam to we pmnsiomnr the conuacmr's uecom Law(Chapter 9 Sq.Ft. Floor Area Valuation
x�$ (commaming with section 700M.f Division 3 oftic Bummossand Preferment;Coca)or
Q`< thus he a exempt therefrom and the buss for the alleged esemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Oe
morn mare than five bundmd dollars(IW. Occupancy Y TYP
0 LumwncroftWprapmy.amymploycmwithwagesudiscmlemmp don,
will do the work,and the suuctum enotinuended oroffbom forma e,(Sere.7066,Business
and Profession Cndc:The Contractors Licene,Law don set apply m an owner of Required Inspections
property wine builds nimpmw Bnrcon.and whodoessuchwarkhimself or through he
mmemployen,provided that such improvements are not intended worn nd fmaale If.
however,the building or improvement a sold within arc year of eempleu.n.that owrcr.
Wilder will have rte Makes of proving Nat W did an Mid or improve for purpose,or
sale
1.es sonar of the property arm exclusively consoling with licemed commissars m
construct the pmjea(Seo.7016,Bviness and Professors Cede:)The Comrano(s U.
cove Law does not apply to an manor of property who MIs;or improm domen.and.
whommuracs forsuch projectswithacontrxmrts)Iie:. dpunmammthe Comraetoh
License sono
IwrmXeJWPL.dnddser See._ ,B&PCfmth
ns ✓^ e n
Ow • `'`-'—— Date �O
WORKERS COMPENSATION DECLARATION
1 WrebY
an under pcvlty of perjury onc mf tin following declanuone ,
I ham and will..low.a certificae,mf(.vent m relr-iume raworkera C.mpen-
"on,u providnd fm by Se'euon 3700 mf de Labor Code,for drat pcRormw of the
work for which this,Pamir is issued.
0 I have and will maintain Workers Compensation Insunnce,as required by Section
37M of the fault Code.for the performance ofthe work,for which this Penni,is issued. '
My Workers Compensation insurance carrier and policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(The section rad!w W completed ifsec peanut Is Were hundred d.11an(SIM)
ser leu)
1 ersufy imt in the performarce of the work for which this permit is issued.l shall set
employ any Person in my mannan as to become subject to the wmkm'Compewtion
Lasso mf Califomia D
NOTICE
E TO APe the Work IL after making this vW mof the
Later on.you should
become subject m the Workers t'ampcwtimn ermit o i of de,demand
Code,you mew
.J Z fwNWidi comply with tnCM1 proviuom or me permit shall W damrA mrptcd. ,
Z OCONSTRUCTION LENDING AGENCY
[•« I Wreby affirm than them is a commuted t lcndineagenry for the performance of
C este work for which this Permit a issued(Sec.3097,Civ.C.)
ip Lsndeh Name
z Lenders Adams
U 0 1 certify that I have reed this application and son that Ne aWw information is
LL F' corm 1 agree in comply with all city and county ordinances and state laws relating be
0 U Wilding conduction,and hereby audience mpresenutim of the city in enter upon the
[17 above.memo mi property,for inspection purposes
0. (Wc)agree to eve,indemnify and keep humless the City of Cupertino moot
pn liabilities,jWgments.costs and expenses which may in my way ocean against mid City
U Z in covequcmc of the Swung of this permit /
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR GU ONL�77 5.
14121 dl X14`k Re-roofs
Signature of AppliunUConmctor Dam �y
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding asupuntnmc or handle baasadov material
as dented by the Cupertino Mumrip 1 Code.Chapter 9.11,and the Health and Safety
Code.Section 15531(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yue o
Will the applicant or future Wilding occupant are equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
B hums us air cmromemm�m tncd by use Bay AreaAir Quality Management all new materials for inspection.
c17
❑Yn o
1 hew mad die hmardons m=daemquim=m under Chapw6.95 of the Califw-
ne)csith&Safety Cod0.Secuom15505.75533and25534.1undrsmundthatifdc building
dors not curmnuy have a count.than it is my responsibility m notify the occupant of the
requite which W sect odor In issuance mf a Cetir, of Occup
Signature of Applicant Date
!�
ownerm.nmmr�<eagem g R All roof coverings to be Class' a'or better
Date"
CITY OF CUPERTINO
• 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32655034 . 01
DATE ISSUED. . . . . . . : 10/31/2008
RECEIPT #. . . . . . . . . : BS000006518
REFERENCE ID # . . . : 08100206
SITE ADDRESS . . : 21044 HAZELBROOK DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : REGNER CUNANAN
ADDRESS 21044 HAZELBROOK DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : REGNER CUNANAN
CONTRACTOR . . . . . . . : MOO POK LEE LIC # 27642
COMPANY . . . . . . . . . . : JL CONSTRUCTION ENTERPRISES
ADDRESS . . . . . . . . . . : 1070 TERRA BELLA AVE
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94043
TELEPHONE . . . . . . . . : (408) 318-1531
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BREMFIXT NO. FIXTURES 1 . 00 61 .19 0 . 00 61 . 19 0 . 00 -
1BSEISMICR VALUATION 100 . 00 0. 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 . 40 .79 0 . 00 40 . 79 0 . 00
---------- ---------- ----------
TOTAL PERMIT • 102 .48 0 . 00 102 . 48 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------- - ------------
CHECK 102 .48 124
---------------
TOTAL RECEIPT 102 .48
O
,
'gym, CITY OF CUPERTINO
CITY Of
• CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
O�6 I b0 20Lp
APN # Date: ( v ^ ? G u
Building Address: 2I.9yY /�� Lgy gFtorll�
Gu �E�i iNo / cA- 9So/Y
Mailing Address (if different from building address):
Owner's Name: Phone#:
iV
Contractor: Phone:��a, �_ $�/3
/,ov PC9-- GES, L GD^�S j Qc�cTrp�
Fax: [6Ct>) 768 — 932`t
Contractor License#: Sy/pg,
Cupertino Business License#:
Contact: AG Phone:C4/�g
• Fax:
Residential Commercial
Job Description:
Ai5hr 6/ !mow
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ I1/III/V-A ❑ II/VI B, IV-HT, V-B
Valuation: Square Footage:
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
• Points Achieved:
For help, contact Build it Green at www.builditgreen.org
Revised 10/20/08