09070083 7777777777777
CITY OF CUPERTINO
BU^.DING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10558 GASCOIGNE DR CHING SUN HSI
NER'S NAME: PERMIT ISSUE DATE
PHON 558J SAN A CONTROL NO.
ARCHITECf7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
POOL DEMO DRILL THREE HOLES
Li 0 c LICENSED CONTRACTOR'S DECLARATION REMAIN THE FRAME, lob Description
jm gI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70(11))of Division 3 of the Business and Professions Code,and my license is
n a. in full force and effect.
Z License Class Lle"
DateContractor
ARCHITECTS DECLARATION
i I understand my plans shall be used as public records
�o.U
O
i- Licensed Professional
n rn 11 OWNER-BUILDER DECLARATION
1 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
K%Ri which requires a permit to construct.alter,improve,demolish,or repair any structure
u Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
E i,< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 :iq.Ft.Floor Area Valuation
YF$ (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&try applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
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 Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q 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 Contractors 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 Contractors
License Law.
❑1 am exempt under Sec. .B&P C for this reason
rrer
Date
WORKER'S CO)MV4,
,WtnON DECLARATION
I hereby affirm under Pey)taity4rl'perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces Compcn-
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
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 arc:
Carrier. Policy 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,I shall not
employ any person in any man r c e subject to the Workers'Compcnsadon
Laws of California Date
Applicant
NOTICE To APP after making this Certificate of Exemption,you should
become subject to t o is Compensation provisions of the Labor Code,you must
,J Q forthwith comply with such provisions or this permit shall be deemed revoked.
z. CONSTRUCTION LENDING AGENCY
Er Qn I hereby affirm that there is a construction lending agency for the performance of _
a> the work for which this permit is issued(See.3097,Civ.C.)
W 0 Lender's Name
z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
W. cones 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 pmpeny for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
o..4 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 n
r" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date / O
SOURCE REGULATIONS.
O Re-roofs
Signature of ApplicanuCo Dale T Of R')Of
US MATERIALS DISCLOSURE Type
Will the applic t or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
c.Section 25532(a)? All roofs,hall be inspected prior to any roofing material being installed.
❑Yes `�(No
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 materials for inspection.
District?
❑Yes C&No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,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
requirements which m t be i nor to issuance of a Certificate of Occupancy. Signature A Applicant Date
All roof coverings to be Class"W'or better
Owner or author' agent Da '
OWNER-BUMDER 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 we rk
C. None of the work
If B or C is checked,c:)mplete 2 or 3 below.
2. A state licensed contractor will be hirec.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
--F
3. _ I will utilize unlicensed person(s) ether 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' con pensation must be on file at the City of
Cupertino Building Department office.
PersorVFirm Address/City . Phone Number Type of work to be
performed
..............................................................................,......................................................................................................
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: ze >L.
Job Address: 11) 55 CYasco;�r -. L��Y��n� / � Permit# _
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF :7UPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 37523006 .00
DATE ISSUED. . . . . . . : 07/08/2009
RECEIPT #. . . . . . . . . BS000008153
REFERENCE ID # . • . : 09070083
SITE ADDRESS . . . . . : 10558 GASCOIGNE DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER CHING YUN HSIANG
ADDRESS . . . . . . . . . . : 10558 GASCOIGNE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CHING Y HSIANG
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY CHING YUN HSIANG
ADDRESS 10558 GASCOIGNE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 000 . 00 1 . 00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 000 . 00 0 .50 0. 00 0 . 50 0 . 00
1DEMOPRE SQUARE FEET 0. 00 490 .00 0 . 00 490 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 491 .50 0 . 00 491 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 491 .50 american express
---------------
TOTAL RECEIPT 491 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
CITY OF CUPERTINO
1 DEMO
CUPEKTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: Q 1 /�
�VrJ�O A col n Cts erLinO CA
Mailing Address (if different from building addr--ss):
Owner's Name: Phone:
Contractor: Phone
Fax:
Contractor License #:
Cupertino Business License #:
Contact: w ner- Phone:
Fax:
Residential lij�-Sq Footage Commercial ❑ Sq Footage
Job Description: t>i-:I l -tkvee, h,�e l Re,.,,.r -0,e -��►^� � ��jQ�,J �i� �s
CtA e-Y-f�0 c f ao'c Yom.MJ,,,1
Valuation:
Project Size: Express ❑ Standard ❑ La-ge ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B ISFDWL-DEM
r 1DEMOPRES Pool Derio Residential B ISFPOOL-DEM
1BCBSC Cal Bldg, Standards B ALL PERMIT
Commis,,;ion Fee TYPES
/ 1BSEISMICRE Seismic :Zesidential B
Revised 01/07/09