09090190 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20956 HOMESTEAD RD#E CONTRACTOR:SMI CONSTRUCTION INC PERMIT NO:09090190
OWNER'S NAME: SUNSHINE WELLNESS 595 MONTAGUE AVE DATE ISSUED:09/25/2009
YER'S PHONE: 4089059839 SAN LEANDRO,CA 94577 PHONE NO:(510)351-3288
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG f- ELECT r PLUMB
License Class Lic.#
Contractor Date MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:GAS METER RELEASE,NEVER HAD ON ORIGL
(commencing with Section 7000)of Division 3 of the Business&Professions PERMIT
Code and that my license is in full force and effect. #07010093
1 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:
Section 3700 of the Labor Code,for the performance of the work for which this Valuation:$500
permit is issued.
APPLICANT CERTIFICATION APN Number:32609061.00 Occupancy Type:
1 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 enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree too 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
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:the without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for saleSec.7044,
( Signature of Applicant:
Business&Professions Code) Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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. 1 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.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized
become subject to the Worker's Compensation provisions of the Labor Code,I must �_Date:
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
inify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
r
Signature Date Licensed Professional
"� o
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32609061 . 00
DATE ISSUED. . . . . . . : 09/25/2009
RECEIPT #. . . . . . . . . : BS000008770
REFERENCE ID # • . . : 09090190
SITE ADDRESS . . . . . : 20956 HOMESTEAD RD #E
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : SUNSHINE WELLNESS
ADDRESS . . . . . . . . . . : 20956 HOMESTEAD RD #E
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1666
RECEIVED FROM . . . . : PEI-CHEN HSU
CONTRACTOR . . . . . . . : RAYMOND SITU LIC # 25182
COMPANY . . . . . . . . . . : SMI CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 595 MONTAGUE AVE
CITY/STATE/ZIP . . . : SAN LEANDRO, CA 94577
TELEPHONE . . . . . . . . : (510) 351-3288
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 500 . 00 1 . 00 0 . 00 1. 00 0 . 00
1BSEISMICO VALUATION 500 . 00 0 . 63 0 .00 0 . 63 0 .00
1PGASCOM OUTLETS 1 . 00 63 . 00 0 . 00 63 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 148 .63 0. 00 148.63 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 148 .63 AMEX
---------------
TOTAL RECEIPT 148 .63
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
507 FINAL PLUMBING
C) ?0 9
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # �0� 0 Date: �,/ _ o
7
Building Address:
Owner's Name: S Phone#: Leo
Contractor: Phone#:
Fax#:
Contact: Phone#: Zpo r,3'- /os
V Fax#:
7
Contractor License#: 7 z
Cupertino Business License#: Z S I v
Job Description: � v-
tl
71 13
Residential ❑ Commercial
Valuation: S�
Project Size: Express EI—StandardEl Large F1 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:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1 PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
f, REPIPE/SEWER/MAIN SERVICE
CITY OF
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1 BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1 TRAVDOC Travel & Documentation Fee B
1 BUSLIC Business License B
k'eful,, Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
XPE�TINO
Building Department
JOB ADDRESS:),V �s-6 �L � PERMIT#
OWNER'S NAME: i cJ PHONE # zi-,� - e-s!"-S, 3
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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/Contractor Signature Date