07030268 CITYOF CUPERTINO
BUILDINGCIVISION PF,Rlvjil
PERMIT NO.
BUILDING ADDRESS:
1187 ELMSFORD DR TBD — 'IO BE DETERMINED 07030268
PERMrr ISSUE DATE
OWNER'S NAME:
BIN WON 03/26/2007
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB IAECH
p p LICENSED CONTRACTOR'S DECLARATION Job D6SCTIptIOn
VF I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70(X))of Division 3 of the Business and Professions Code,and my license is FURNACE F; REPLACEMENT/ADD AIR CONDITIONING
>>y in full force and effect./r7,l�
n? License Cl Vr� Lie.n SUM SAND I Ur[
t-w Date IL/A/�Contractor
ARCHITECTS
ARA110R- HAS BUS LIC #28867
i a a I understand my plans shall be used as public records
>yU
U.H Licensed Professional
y as OWNER-BUILDER DECLARATION
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
c Z prior to its 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 7 O O 0
a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i R E that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(5500). 3 6 2 0 8 0 �1 . (
1,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
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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
ccnse 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 Contractors
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for workers compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 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.
Worker �te
Consation)'UNIrspee_t�d Polity number
Carrier ~ w Ii 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,1 shall not
employ any person in any manner so as to become subject to the Workcrs'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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z— CONSTRUCTION LENDING AGENCY
Cn I hereby affirm that there is a construction lending agency for the performance of
(Y > the work for which this permit is issued(Sec.3097,Civ.C-)
W Q Lender's Name
Lender's Address
Z
U 0 I certify that 1 have read this application and state that the above information is
-. correct.1 agree to comply with all city and county ordinances and state laws relating to
rJ Jbuilding construction,and hereby authorise representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued ty:
S OU RC3AJUILATIONS.
^ti. 3 .Z 41 d1 Re-roof
Signature o Appli onrutor Dare Type of Roof
HAZARDOUS 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
Code,Section 25532(a)? All roots shall be inspected prior to any roofing material being installed.
0 Yes
Will the applicant or future building occupant use equipment or devices which
If a roo:'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 materials for inspection.
District?
0 Yes o
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 noLparntly have a tenant,that it is my responsibility to notify the occupant of the
icy c which mus c m or to issuance of a Ccrdfica f C)Rc�cy Signatu-e of Applicant Date
�— 1 ,a All roof coverings to be Class"B"or better
Owner or authorized agent — ate
CITY OF CUPERTINO
U N CE/ � �: �
alF
CUPEI�TINO PERMIT APPLICATION FORM
APN# � �� 6�-
Date:
Building Address: ` l S-7
Owner's Name: Phone#:
4$ 94 ga"7 z..
Contractor: Phone: License#:Q�
417 s �o7z g
Contact: Phone: Cupertino Business License#:
W :� b1062941G
Building Permit Info:
Bldg ❑ Elect E]/ 3lumb Er—' Mech 17'
Job Description: `
C 44U
Residential K Commercial ❑
For Residential Ins llations:
Attic F-1 1St floor 2nd floor❑
Adhere to min set back requirement
For Commercial Installations:
-placement same weight ❑ Additional weight(structural talcs)❑
Structural Calculations required for new installation ❑
New installation Planning Approval Re uired ❑
Cost of Project: Type of Constry tion: Occupanc�gr p:
Strapped ❑ On Platform Bonded Er Sq.Ft. Floor Area:
New Location d Replacement-ET
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER Y�-/C Unit> 10,000 cfin MECHANICAL
BREMAIRHAN YX Units<= 10, 000 cfm MECHANICAL
BREMRECEPT Recptl, Switch& Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM ,)eismic Commercial BUILIDNG
EPERMITFEE Ellec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK flan Check Fee BUILDING
BPGAS Jas Piping System Fee PLUMBING
BUILDING
BUSLIC .3usiness License
CITY OF' CUPERTINO
^' 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: suew
COPY $# 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 3E208031. 00
DATE ISSUED. . . . . . . : 0_ /26/2007
RECEIPT #. . . . . . . . . : BE000000788
REFERENCE ID # . . . : 0; 030268
SITE ADDRESS . . . . . : 17.87 ELMSFORD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER BIN WON
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO, 95070-5452
RECEIVED FROM . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : TESD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TDD - TO BE DETERMINED
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----------- ---------- ---------- ----------
BENERGY PERMIT FEE 1 .00 34 .86 0 .00 34 .86 0. 00
BREMAIRHAN NO.UNITS 1.00 10 .26 0 .00 10 .26 0. 00
BREMFURN NO UNIT 1.00 14 .31 0 . 00 14 .31 0. 00
BREMRECEPT NO. OUTLETS 1 .00 1.20 0 . 00 1 .20 0. 00
BSEISMICRE VALUATION 7, 000 .00 0.70 0 .00 0 .70 0. 00
EPERMITFEE FLAT RATE 1 .00 38 .37 0 .00 38 .37 0 .00
MPERMITFEE FLAT RATE 1.00 38 .37 0 .00 38 .37 0 .00
PPERMITFEE FLAT RATE 1 .00 38.37 0 .00 38.37 0. 00
----------- ---------- ---------- ----------
TOTAL PERMIT 176.44 0.00 176 .44 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 176.44 VISA
---------------
TOTAL RECEIPT 176 .44
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- --------------------------- ------ ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL