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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
20865 PEPPER TREE LA
OWNER'S NAME:
JOHN TONG
INE:
ARCHITECTIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and fie L
f
License Class _ —20 Lic. #
Date Contractor
ARMITECT-S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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
prior m its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars (5500).
❑ 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
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, die 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 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 Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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 Worker's Compensation Insurance, as required by Section
3710 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker nsatiog]nsutan arricr and Polity m cr
Carrier. Policy N...
.MD
ATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($110)
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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namc
Lender's Address
I certify that I have rad this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGLATIONS.
r4A_Q_rn� �O1-2- /n
Signature of ApplicanUComractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipa Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?
❑ Yes o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as d fined by the Bay Area Air Quality Management
District?
❑ Ycs ( o
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
does not currently have a tenant, that it is my responsibility to notify the Occupant of the
requireme which must be mel prior w issuance of a Certificate of Ot:cupancy.
r / 17,1L0,6
Owner or authorized agent Date
CTRICAL
10628 RANDY LN
(408)366-1823
PERMIT No. 06100184
PERMIT ISSUE DATE
10/26/2006
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
REPLACE FURNACE & ADD A/C
Ft. Floor Area
Issued by:
Re -roofs
Type of Roof
Required Inspections
5200
Valuation
Occupancy Type
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
CITY Of
'"'UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT # 6��
OWNER'S N
PHONE #
GENERAL CONTRACTOR
FAX #
I am not using any subcontractors: i--'
Signature
P1Pa,;e rbeck annlicable subcontractors and comvlete the following information:
O 2,6 9-4
Date
Owner/Contractor Signature
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 Signature
Date
'm
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........:35912010.00
DATE ISSUED.......: 10/26/2006
RECEIPT #......... 36568
REFERENCE ID # ...: 06100184
SITE ADDRESS ......
SUBDIVISION ......
CITY .............
IMPACT AREA ......
OWNER ............
ADDRESS ..........
CITY/STATE/ZIP ...
20865 PEPPER TREE LA
CUPERTINO
JOHN TONG
OPERATOR: amyw
COPY # : 3
RECEIVED FROM QUANS ELECTRICAL
CONTRACTOR HIEN Q TRUONG LIC # 23332
COMPANY QUAN'S ELECTRICAL
ADDRESS 10628 RANDY LN
CITY/STATE/ZIP CUPERTINO, CA 95014
TELEPHONE (408)366-1823
FEE ID UNIT
QUANTITY
AMOUNT
----
PD -TO -DT
THIS REC NEW
BAL
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
BENERGY PERMIT FEE
1.00
34.86
0.00
34.86
0.00
BREMRECEPT NO. OUTLETS
1.00
1.20
0.00
1.20
0.00
PPERMITFEE FLAT RATE
1.00
38.37
0.00
38.37
0.00
BSEISMICRE VALUATION
6,000.00
0.60
0.00
0.60
0.00
EPERMITFEE FLAT RATE
1.00
38.37
0.00
38.37
0.00
MPERMITFEE FLAT RATE
1.00
38.37
------0_00
------ ------
----
TOTAL PERMIT
176.34
0.00
176.34
0.00
METHOD OF PAYMENT
AMOUNT
NUMBER
---------------
----------------- ------------
OTHER
176.34
VISA
TOTAL RECEIPT
176.34
VOICE ID DESCRIPTION
VOICE
ID
DESCRIPTION
301 ROUGH PLUMBING
303
----
ROUGH
MECHANICAL
304 ROUGH ELECTRICAL
505
FINAL
ELECTRICAL
507 FINAL PLUMBING
508
FINAL
MECHANICAL
400F
f:UPEkTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
APN # 3tci 2 "
Building Addr ss:
Owner'! N.�uze:
Contracto
Building Permit Info:
Bldg ❑
Job Description:
Residential C
Phone:
Phone:
Elect
J (''
Commercial ❑
Date: i o% � jo
Plumb D"
' Phone #:
License #:
Cupertino Business License #:
For Residential Installations:
Attic ❑ Is' floor ❑ 2nd floor ❑
Adhere to min set back requirement [L��
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: J Type of Construction:
Strapped ❑ On Platform El— Bond6d LJ'
New Location -D
Qty. if
Applicable Fee ID
BENERGY
E Ell- BREMFURN
BREMACOVER
BREMAIRHAN
BREMRECEPT
BSEISMICRE
BSEISMICOM
EPERMITFEE
MPERMITFEE
PPERMITFEE
BPERMFEE
BPLANCHK
BPGAS
BUSLIC
Mech ffK
Occupancy group:
Sq.Ft. Floor Area:
Fee Description
Fee Group
Energy
BUILDING
Furnace
MECHANICAL
A/C Unit > 10,000 cfin
MECHANICAL
A/C Units <= 10, 000 cfm
MECHANICAL
Recptl, Switch & Outlets
ELECTRICAL
Seismic Fee Res
BUILDING
Seismic Commercial
BUILIDNG
Elec Permit Issuance
ELECTRICAL
Mech Permit Issuance
MECHANICAL
Plumbing Permit Issue
PLUMBING
Bldg Permit Fees
BUILDING
Plan Check Fee
BUILDING
Gas Piping System Fee
PLUMBING
Business License
BUILDING