07030132 7777777777777777
CITY OF CVPERTIl O
BUILDING DIVISIONPERMIT �a'- N RM�TIc N'
BUILDING ADDRESS: PERMIT NO.
10955 DRYDEN AV CUPERTINO PLUMBING 07030132
OWNER'S NAME: PERMIT ISSUE DATE
• HUANG AGNUS 1300 DELL AVE STE C 03/19/2007
:VE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i c O LICENSED CONTRACTOR'S DECLARATION
L J I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
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with Section 7000)of Division 3 of thc Business and Professions Codc,and my license is WATER MAIN ONLY
rn in full force and e feet e f�v
? License Class Lie.N Y
;F n Date — ContractorKK
a
ARCHITECTS DECLARAT101
UI understand my plans shall be used as public records
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o y Licensed Professional
�y OWNER-BUILDER DECLARATION
j e I hereby affirm that 1 am exempt from the Contractor's License Law for the
_p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
< which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
e that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 >q.Ft. Floor Area Valuation
t m (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1000
i 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 A��l Number Occupancy Type
not more than five hundred dollars(5500). 3 5 6 14 0 1 aV U.
❑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 ns'Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of (l P
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 Conuactor'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 Comnctoes
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I I 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 Workers 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 ate:
Cartier._2e-t!'t(-- Polity No.: 2 1Sft—6—"5
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE !iANI
(This section need not be completed if the permit is for one hundred dollars($100) TARY
or Icss.)
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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
"7-O CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
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the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
2 Lcnder's Address
U 0 1 certify that I have read this application and state that the above information is
U. ► correct.I agree to comply with all city and county ordinances and state laws relating to
H building construction,and hereby authome representatives of this city to enter upon the
r a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
f) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granftUof this permit.
APPLICA S L COMPLY WITH ALL NON-POINT Issued by: Date J I
REGUL
Re-roofs
Sign ofApplicigutl6tractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of R(,of
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)?
❑Ycs No All roofs s'lall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is 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 mE serials for inspection.
District? �
❑Yes er
I 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
does not currently have a tenant,th ' my responsibility to notify the occupant of the
rauiremcnts which m w issuance of Certificate of Occupancy. Signature(f Applicant Date
g —
v All roof coverings to be Class"B"or better
Owner or uthorized a Date
CITY OF CUPERTINO
2 ITEMS OF 4 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 1
Sec : Twp: Rng: Sub: B11: Lot :
APN 35C14019 . 00
DATE ISSUED. . . . . . . : 03/19/2007
RECEIPT #. . . . . . . . . BS000000718
REFERENCE ID # . . . : 07030132
SITE ADDRESS . . . . . : 10955 DRYDEN AV
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER HUANG AGNUS
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4745
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : CARDIA, FRANK L LIC # 612
COMPANY . . . . . . . . . . : CUERTINO PLUMBING
ADDRESS . . . . . . . . . . : 1300 DELL AVE, STE C
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (4 )8) 253-0618
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ----
BPWSVCS WATER SERVICE 1. 00 9 . 00 0 . 00 9 . 00 0 .00
PPERMITFEE FLAT RATE 1. 00 38 .37 0 . 00 38 .37 0 . 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 47 .37 0 . 00 47 .37 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----------
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
CITY OF CUPERTINO
REPIPE/ VV ,! /MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM 0j03 0)3o
ot
APN # 3 J�lY^+ 1r_ O 1 Date:
Z
3 -t-?-
Building Address:
/C)9 S S
Owner's Name: Phone#: _
-
C tra or: Phone: License #:
IiL) =ZS 3 —C�C� (� ?o
Contact. Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb l�'r
Job Description:
Residential �� Commercial ❑
Cost of Project: `( C) U
Qty. if
Applicable Fee ID _ Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE I'blg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE 'S'ewage Disposal PLUMBING
BUSLIC Business License BUILDING