11080027 ,
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20109 LAS ONDAS WAY CONTRACTOR:SANDIUM PERMIT NO: 11080027
OWNER'S NAME: LEE TONG-MING 4223 VERDIGRIS CIR DATE ISSUED:08/03/2011
R" "ER'S PHONE: 5102077493 SAN JOSE,CA 95134 PHONE NO:(408)894-9072
G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT F PLUMB
License Class Lic.#
., p MECH' RESIDENTIAL� COMMERCIAL
Contractor �ta.c_ Date o
JOB DESCRIPTION:REPLACE FURNACE&ADD A/C;ADHERE TO MIN SFT
I hereby affirm that I am licensed under the provisions of Chapter 9
SETBACK REQUIREMENT
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by Sq.Ft Floor Area: Valuation:$6700
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36932033.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section /
9.18. Issued Date:
Signature zl_�. Date P/3/1
( '
RE-ROOFS:
OWNER-BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owe or orized a
DateI
become subject to the Worker's Compensation provisions of the Labor Code,I must r
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
r and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
ig of this permit.Additionally,the applicant understands and will comply
e, a all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
GENERAL PERM T APPLICATION _ MEP
-
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX (408)777-3333 • buildinG(8cuoertino.org MISC
ERPLUIv1BING N1zCrLA1F:CAL LEC UCAL ❑MISCELLANEOUS
PROJECT ADDRESS n 0 _fl 1 , 5 N m
OWNER NAME nt_ L , (mL u A PHONE
21
STREET ADDRESS [lot,_,A as . O(_L&-5
�/ CITY, STATE,ZIP, J FAX
CONTACT NAME r� PHONE E-MAII
STREET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME K � 1 (�/�•_� LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME ` ►f E-MAIL ` FAX
STREET ADDRESS CITY,STATE,ZLPSam ` S`N PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER J BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
JSE OF SFD or DUPLEX ❑ MULTI-FANnY PROTECT IN wiLDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK ( 1
1. d 1v m
^!� -,yV,w►en:r
TOTAL VALUATION: 00 O RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct.,.I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ing
ordinances and state laws relatto b � g construction:.I authorize representatives of Cupertino to enter the above-identi ed property for inspection poses.
Signature of ApplicandAgent: Date:43 Zi
SUPPLEIVIEN I'AL INFORIVATION REQ=D OFFICE USE ONLY
❑ OVER-THE-COUNTER
a
❑ EXPRESS
s
U
w ❑ STANDARD
U
❑ LARGE
❑ MAJOR
MEPJlfsscApp_2011.doc revised 06121111