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09010058 CITY OF CUPERTINOiOT BUILDING DI'7SION PERMIT � � !� '` PERMIT NO. BUILDING ADDRESS: , 09010058 22080 SAN FERNANDO CT ALEX ANO NUEV PERMIT ISSUE DATE OWNER'S NAME: D T F X r r I r SAN CONTROL NO. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH TEMP PERMIT D D D 0 a c LICENSED CONTRACTOR'S DECLARATION Job Description V1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 70(10)of Division 3 of the Business and Professions Code,and my license is y in full force and effort Z License Clan Lic- p Date Contractor 3 t- ARCHITECTS DECLARATION I understand my plans shall be used as public records O H Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the 20 following reason.(Section 7031.5,Business and Professions Code:Any city or county t.9 which requires a permit to construct,alter,improve.demolish,or repair any structure n"y prior b its issuance,also requires the applicant for such permit to file a signed statement q,Ft.Floor Area Valuation 1<2 that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 S yt– (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 Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than rive hundred dollars(S500). ❑I,as owner of the property,or my employees with wages as their solo compensation, win do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractors License Law dots 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 arc not intended or offered for sale.If, i 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 Contractors u. cense Law does not apply to a owner of property who builds or improves thereon,and, who contracts for such pmje s with a contractor(s)licensed pursuant to the Contractors License � ❑I exempt under, B&P C for s n Owner C/ Dare 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-insure for Workers Compen- -don,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 Workers Compensation insurance carrier and Policy number am: Cama; Policy No.: CERTIFICATE OF EXE0TION FROM WORKERS' COMPENSATION INSURANCE (Mis section need not be completed if the permit is for one hundred dollars(S 100) or Icss.) I certify that in the perfo cc ofAc work for which this permit is issued.I shall not employ any person in an as to become sub' t to the Workers'Compensation Laws of California. Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,yo shout become subject to the Worker's Compensation provisions of the Labor Code,you mast Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is s consuuctinn lending agency for the performance of the work for which Nis permit is issued(Sec,3097,Civ.C.) W ALenders Name aZ Lenders Address I certify that I have read this application and state that the above information is comet I agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes C4 (We)agree to scare;ifidc' ify and keep harmless the City of Cupertino against vj liabilities,jtrdgmcnts,toss and a which may in any way accrue against said City I .' U Z in consequence of the granting o rs permit Date ` r�i4 r APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: SOU�CE REGULATIONS — 3 Re-roofs Signature ofApplicant/Co for Date of Roof HAZARDOUS MATERIALS DISCLOSURE Type 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(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑ o J If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building nt use equipment or devices which all new materials for inspection. it hazardous air conumunan do y Nc Bay Area Air Quality Management .strict? ❑Yes No 1 have madtlfah8zardous materials requirements under Chapter 6.95 of the Califor- nia Health&S�fcty C 'ons 75505.25533 and 25534.l understand that if the building docs noLc�uis w'y have ant.Nat it is my responsibility to notify the occupant of the Date rcquodmcnts which met Prior to issuance of a Certificate octupZcy/C/ Signature of Applicant �J All roof coverings to be Classor better Owner or authorized agent Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35712011 . 00 DATE ISSUED. . . . . . . . 01/13/2009 RECEIPT # . . . . . . . . . . BS000006965 REFERENCE ID # . . . : 09010058 SITE ADDRESS 22080 SAN FERNANDO CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ALEX ANO NUEVO & LILY DONG ADDRESS 22080 SAN FERNANDO CT CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM . . . . : ALEXANDER ANONUEVO CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : ALEX ANO NUEVO & LILY DONG ADDRESS . . . . . . . . . . : 22080 SAN FERNANDO CT 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 1EPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00 1ERT<200 UNITS 1. 00 40 . 79 0 . 00 40 . 79 0 . 00 1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 123 . 87 0 . 00 123 . 87 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 123 . 87 CASH --------------- TOTAL RECEIPT 123 . 87 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----- 402 TEMPORARY POWER CITY OF CUPERTINO TEMP POWER CUPERTINO PERMIT APPLICATION FORM ngoab5-Sx APN # 3 s_ -- 00 Date: s Building Address: C- Z Owner's Name: Phone#: 14 lex q-,do- 4 0 n ue t10 C14-0-C6- - Z Contractor: Phone #: �'1 r /4v`�� S 5 7- S 3 3 Fax#: Contact: Phone#: Contractor License #: Cupertino Business License #: Job Description: Residential Commercial Valuation (cost of project): z5 0 Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>lK Res. Temp Power>1K E 1REAP14 Amps IERT<200 Res. Temp Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K E Amps / IEPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E 1BSEISMICR Seismic Residential B ITRAVDOC Travel & Documentation B Fee 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. Person/Firm Address/City Phone Number Type of work to be erf ormed ..................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the 11 Owner-Builder Information erse de). Property Owner's Signatur - ' Date: Job Address: C r �117<t n �l,,, Permit# AnXchanges to the information provided on this form shall be submitted to the City of Cupertino Build Department. Community Development 10300 Torre Avenue 1Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408)777-3333 'WEkTINO Building Department JOB ADDRESS: PERMIT # 0 S- OWNER'S NAME: 44z - PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractor: Signature Date Please check applicable subcontractors and complete the following information: 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/ContFactor Signature Date