07060052 CITY OF CUPERTINO
BUILD:NG DIVisloN PERMIT '�
PERMIT NO.
BUILT�IIfG/1QDjiEs�N DR NATIONAL CONSTRUCTION 07060052
FEN rAT7S T U l(�L� PERMIT ISSUE DATE
OWNER'S NAME:
BO LIU 15319 CHATSWORTH ST 06/07/2007
SANITARY NO. CONTROL NO.
NE:
(818) 221-6057
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p Q LICENSED CONTRACTOR'S DECLARATION Job Description
w F I hereby affirm that I am licensed under provisions o[Chapter 9(commencing
U 8 with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMPORARY POWER POLE
!7 y in full force and effect.
j ? License Class Lic.N
o Date Contractor
ARCHITECTS DECLARATION
j� a
< I understand my plans shall be used as public records
�a.U
U.y Licensed Professional
o a OWNER-BUILDER DECLARATION
� [hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Calc:Any city or county
which requires a permit to concoct,atter,improve,demolish,or repair any structure
a prior to its issuance,also requires the applicant for such permit to file a signed statemente Ft.Floor Area Valuation
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q• $350
e.tT (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 32619008 .�Number
not more than five hundred dollars($500).
❑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 oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not 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.).
❑I,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 docs 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 Sec B&P C for this reason
Owner ^A Date��
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Worker's Compcn-
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 Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so beco c subject to the Workers'Compensation
Laws of California.Date- A �{"�
Applicant
NOTICE TO APPLICANT:If,after making this Ccltitycatpbf Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
Er I hereby affirm that there is a concoction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U CI certify that I have read this application and state that the above information is
E correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
Uabove-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 ULATTONS.
0e,
Gl7l 7 Re-roofs
Sig�6 Applicant/Contractor Dare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
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
Code,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes KN.
Will the applicant or future building occupant use equipment or devices which
If a roof i;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 JQ No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs 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 Of Signature of Applicant Date
� All roof coverings to be Class"B"or better
Owner or authonz� Date
i CITY OF C UPERTINO
'Ei P 130E
CIT�UPEI�TINO PERMIT APPLICATION FORM
APN# Date:
-'
-17.216 --( - O O
R 1-7
Building Address:
/� i � 41n 14L
Owner's Name: Phone #: f
Contractor- Phone: License #:
2v 2-70D 6 ' / $
Contact: Phone: Cupertino Business License #:
k, , Z - Z BZW S.3
Building
Permit Info:
Elect
Job Description:
Residential [XL Commercial EY
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC B-.isiness License BUILDING
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITI(OF Fax(408)777-3333
7UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
OWNER'S NAME: G u PHONE
GENERAL CONTRACTOR: .�,} ;�,.«,,t FAX#
I am not using any subcontractors: G l a
Si;;nature Date
Please check applicable subcontractors and complete the following information:
RI 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
67
Owner/Contractor Signature Date