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09010026 CITY OF CUPERTINO BUILDING DIVISION PERMITt1Rt ( � � � * BUILDING ADDRESS: PERMIT NO. 20903 FARGO DR CHENG— — OW NER's NAME: PERMIT ISSUE DATE '2899 °HO SAN CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO WATER HEATER BLDG ELECT PLUMB O u O p LICENSED CONTRACTOR'S DECLARATION U with Section 7000)of Division 3 of the Business and Professions Code.and my license is y in full fora and effect. r�z License Class Lic.N y in 3 Dale Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records �yU 4 O N Licensed Professional y 3 OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the COO following mason.(Section 70315,Business and Professions Code:Any city or county $P which requires a permit to construct,alter,improve,demolish,or repair any structure y y prior to 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 Ligase law(Chapter 9 Sq.Ft.Floor Area Valuation t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y .. 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 APN Number Occupancy Type not more than five hundred dollars(5500). ❑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 and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections 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) t,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 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 Contractor's License Law. ❑lam exempt der Sec. B&P C for this reason Owner y Datel ' W 'RK 'S C ! 1 SAT[ON DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to SWAM=for worker's Compcn- .ion,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑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 My Workees Compensation Insurance carrier and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section reed not be completed if the permit is for on hundred dollars($100) or Icss.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any mann so at to beco Laws of C!��ia.Datebject to the Workers'Compensation AppliPA NOTICE A L] :IT,alter g chis r nate of Exemption,you should become subject to Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z r--r CONSTRUCTION LENDING AGENCY E-+rA I hereby affirm that there is a construction lending agency for the performance of ai> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lendees Name Z Lender's Address V Q 1 certify that 1 have read this application and state that the above information is (y correct I agree to comply with all city and county ordinances and state laws relating to 0V building convection,and hereby authorize representatives of this city to enter upon the a above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against tF"y to liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS ANDWILL OMPLY WITH ALL NON-POINT Issued by: Date r �' SOURCE R GULAMONS. Re-roofs Si re of App' 11Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof 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 Cole,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yea (DXV-­, 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 :t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. u ict? ❑Yes CUT-- I UT -t have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand thatt if the building docs not currently have a tenant,that itis my ponsibility to notify the occupant of the requirements. hich must be I pri to i mf a Ccnificae of Occupancy. Signature of Applicant Date Owner or auth 4Ld agent Date All roof coverings to be Class" "or better CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . . 32630136 . 00 DATE ISSUED. . . . . . . : 01/07/2009 RECEIPT #. . . . . . . . . . BS000006920 REFERENCE ID # . . . : 09010026 SITE ADDRESS . . . . . : 20903 FARGO DR SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHENG-CHI AND KUEI-CHEN LIU ADDRESS . . . . . . . . . . : 20903 FARGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHENG CHI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : CHENG-CHI AND KUEI-CHEN LIU ADDRESS . . . . . . . . . . . 20903 FARGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 1PRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24 .48 0 . 00 1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 107 . 56 0 . 00 107 . 56 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 107 . 56 --------------- TOTAL RECEIPT 107 . 56 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER CITY OF CUPERTINO WATER HEATER CUPEIIiTINO PERMIT APPLICATION FORM APN # - - ate: ?� . - �4P Building Address: O Owner's Name: Phone #: 1 d 4-16 664f r&3 Contractor: // Phone #: l � Fax #: Cupertino Business License #: Contractor State License #: Contact: Phone #: Fax #: Building Permit Info: Bldg Elect ❑_, Plumb Mech [� Residential ❑ Commercial ❑ Job Description: IkT Strapped On Platform Bonded ❑ New Location ❑ Replacement Valuation (cost of project): S-0 o Project Size: Express ❑ Standard V1 Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: Revised 6/16/08 CITY OF CUPERTINO WATER HEATER CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWHEATR Commercial Water B PCWHEATR HeaterNent 1BSEISMICOM Seismic Commercial B 1PRWHEATR Residential Water B PRWHEATR HeaterNent 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1 BUSLIC Business License B Community Development :W *. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 �JCITY OF Fax(408)777-3333 ''UPEkTINO Buildfin-a De artment JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE #S"l0- GENERAL CONTRAC OR: 0 oln I FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSt # 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 OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child)will perform: A. All the work authorized by this permit B. — A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. — All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone Number Type of work to be erformed ......................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(reverse side). Property Owner's Signature: � � Date: Job Address: 2-0�� 3 ��y Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department.