07100084 CITY OF CUPERTINO `
BUI[A[NG DIV4S10N PERMIT C��T����aR I����'z`IE� _:
_ , ,. , ; _ __.: .
BUILD[NG ADDRESS: PERMIT NO.
7507 BOLLINGER RD D& D CJNSTRUCTION 07100084 �
PERMIT LSSUE DATE
OWNER'S NAME:
' JAMIN HE 1447 HAKPTON
SANITARY NO. CON7'ROL NO.
NE:
(408)666-5298
BUILDING PERMIT 1NP0
ARC HIT'ECC/ENGINEER:
BLDG ELECT PLUMB MECH
� 0 0 0
i p p LICENSED CONTRACTOR'S DECLARAT[ON JOI� DeSCflPt10❑
i V F' ��by aC(irm that I am liccnscd undcr provisions of Chaptcr 9(cammencing
; z� wiih Scction 700t)) af Divi�ion 3 of ihc Busincss and Profcssiuns Codc and my liccnsc is TEMPOR.A R �� POWEP. POLE
�< a � fuli fose and eCfec�
j� Z Licensc Class — Lic. #
: F � pa� Contractor
� ARCHITECI'S DECLARATION
i a a 1 undcrstanJ my plans shall bc used as public reconls
)aU
' u. F" Liccnsed Profcssional
`y � OWNER-BUIIDER DECLARATION
t hcrchy aCGrm Ihat 1 am excmpt Crom thc Contractor's Liccnsc L.aw far �hc
� p O (ollowing rcason. (Sccuon 7031.5, Busincss and Profcssions Calc: Any city or caun�y
�$�i which requires a permit tu conswct, altcr. improve, dcmolish, or rep�ir any suucturc
� Z y prior w i�s issuance, also �zquires �he applicant for such permit ta fiie a signed staiement Valuation
- a �hat hc is liccnud pursuant to thc provisions o[ thc Conuactor's Liccnsc Law (Chaptcr 9 ;>q. Ft. Floor Area
r F� (commcncing wiih Scction 7000) of Division 3 of Ihc Busincss and Profcssions Codc) or $ 1 Q Q
i�� �hat he is ezempt thciefrom and the basis Cor the allegcd exemption. Any viotation at
Section 7031.5 by arry applicant tor a petmic subjec�s �he applicant to a civil penalty of Number Occupancy Type
not more than fivc hundred dollars (SS00). 3' 9 2 3 Q 2 8��
❑ I, as owner o( tl�e property, or my cmployces with wages az the'v solc compensation,
will do thc work, and �:c stzuctwe is not intendcd or af[eztd forsalc (Sec. 7044. Busineu Required Inspections
and Professions Cade: The Conuacwr's License Law dacs not apply w an owner af
propeny wha builds or impraves �hercon, and wha does such worlc himseif or theough 6is
own employccs, providcd that such improvements are not intended ar oRered for sale. IC,
Aowever, the building or improvement is sold within one yesr oC complcdon, ihe ownu-
buildu will have Uu burden af proving that M did not build or improvc fw pmpeue af
sale.).
, as owner of ihe pcoperry, am exclusivety conuacting wi�h licenud rnnuxWrs to
construa the pcojm (Sec. 7044. Business and Profcssions CodeJ'Ihe Coatnanrs Li-
cense Law docs not apply to an owner of property who builds or improves Ihereon. �nd ,
who contracts tor such pmjects with a convactor(s) licensed pursuant w ihe Con�rutars
License I.aw.
❑ 1 am ezempt under Sec , B& P C for this rcaaon
Owner ,1 i�G1„'�� L� Da L� ! tJ �� _. _
�� WORKER'S COMPENSATION DECLARATION
I hercby affirm under penalty o[ perjury onc o[ the fotiowing declara�ians:
� I hsve and will mainisin a CcrtiGcam of Conscnt lo ul(-insurc for Workers Campen-
sation, u providcd for by Seccian 3700 of �Ae Labor Code. for thc performanm of �he
work for which this pertnit is issucd.
❑ I have and will maintain Worker's Compensauon Insurance, as �equired by Section
3700 af �he Labar Code, Cw ihe performance ot the work for which this permit is issued.
My Worker's Compensatioa insuwncc carrier and Policy numbcr are:
Carrier. Policy No.:
CER'fIFiCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(17�is section necd not be complctcd it the permit is for onc hundred doilua (5100)
nr IcssJ
1 cenify thxt in thc per(ormancc of We work for which this pertnit is issucd, 1 shall not
e�ploy any person in any mannc�� �bjcct ta the Workcrs' Compensation
Laws of Califomia. Dalc � � '
Applicant .
NOTICE'f0 APPLICA I, aftcr making Wis CcniGcatc of Ezcmption, yau should
bccome subjcct to Wc Workci s Compcnsation provisions of Uic Lahor Codc, yau must
� O foMwith comply with such provisions or this pccmit shall6c dccmcd mrokcd.
� ""' CONSTRUCTION LENDING AGENCY
(.�-� ��-. t herehy aftirtn �hat there is a conswcuon Iending agency for the performance af
CC, � ttic wurk Cur wAich this permit is issucd (Scc. 3097, Civ. C.)
W Q Lendet's Namc �
j z L.cnder's Address
V � 1 ceni[y iha� 1 have rcad this applieation and siate that the above infamation is
w �-' cortect. I agrce �o comply with all ciry and county ortlinances and state laws eeladng to
0 U building conswction, and hcreby authorim reprcscnta�ivcs of �his ci�y to cntcr u{mn tAc
� W abovc-mcntioncd property (or inspccdon purposes.
a (We) agrce to save, indcmnify and kecp harmless thc Ciiy of Cupcnino against
�,� � liabilitiu, judgmcnLS, costs and expcnscs which may in any way accruc againsl said Ci�y / � J
U z in consequence oC �he granting of �his pertnit. Ddte �(���
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIM' Issued by _
SOURCE REGULA'I70NS.
l �y��. /�._--- GO �o� 7 Re-roofs �c_�
Signa o(ApplicanUContractor �� T e of Roof
HAZARDOUS MATERIALS DISCLOSURE }�P
Wit1 ihc appticant or futurc building accupant storc or handlc ha�ardous ma�crial
as dcfined by the Cupenino Municipal Codc. Chap�cr 9.12, and �hc Hcalth and SaCcty
c� Scction 25532(a)? dNo All roofs �hall be inspected prior to any roofing material being installed.
❑ Y� .
If a roof i� installed without first obtaining an inspection, I agree to remove
Will thc applicant or fuwrc building occupant usc eyuipmcnt or dcviccs whic6 -
cmii harardous air contaminants as cle6ncd by the Bay Arca Air Quality ManagcmeM all new rr aterials for inspecr.ion. �
��su��c? �/
❑ vcs Q�u
1 havc mad �he ha�ardcws matcrials rcquiremcn�s undcr Chap�cr 6.95 of �hc Califor-
nia Hcal�h & Safcty Codc. Scctions 25505, 25533 and 25534. f �ndcrstand Uwt it ihc building
- �ocs no� curren�ly havc a tcnant, that it is my responsibility w notil'y thc oceupani of thc
rcyuj���wni� t bc me prior �o issuancc o(a Ccrtificatc of Oc� a Signature of Applicant Date
All roof coverings to be Class "B ' or better
Ow or authorizcd agcm ���
�� /C�C.� C� �L�
� CITY OF C'UPERTINO
`�� �;.� �`�' I� � ���'��
CUP�I�TINO PERMIT APPL=[CATION FOR1V�
Date:
o��� .�� � �'� 0 C� !d -io �-2oe7
Building Address:
7SoJ L��l(rn ��' �d , �c�i �r�%�HD C'A �.��/
Owner's Name: Phone #:
; �J r'�r � � � `-,Zs�3--76D`�
- -- ---- _--------- --- --- ----- — ------ -- — - - - - - ---- -- - -
� ContiacCor: Phone: Licensc, #: �'
��r�v�� W� 4-��-�-.�2�� ��776�
Contact: Phone: Cupertino Business License #:
� c�-r J � �� �
Building Permit Info: +'
Elect ❑ �2 tv� r��a r� l.u��� J 1-Q.
Job Description:
Residential [�— Commercial ❑
Cost of Project:
��
Qty. if
Applicable Fee ID Fee Descri tion Fee Grou
BTEMP Tem orary Power ELECTRICAL
EPERMITFEE El�.ct. Permit Issuance ELECTRICAL
BUSLIC BL siness License BIJILDING
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI7' RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN ......... 35��23028.00
DATE ISSUED.......: 10i10/2007
RECEIPT #.........: BS(i00002949
REFERENCE ID # ...: 07�.00084
SITE ADDRESS .....: 75(�7 BOLLINGER RD
SUBDIVISION .......
CITY .............. CUF'ERTINO
IMPACT AREA .......
OWNER ............. JA1�fIN HE
ADDRESS ..........: 75(17 BOLLINGER RD
CITY/STATE/ZIP ...: CU�'ERTINO, CA 95014
RECEIVED FROM .. ..: JI��NiIN HE
CONTRACTOR .......: ETTI>E WU LIC # 2 3 9 3 9
COMPANY ..........: D F: D CONSTRUCTION
ADDRESS ..........: 14�:7 HAMPTON DR
CITY/STATE/ZIP ...: SUf]NYVALE, CA 94087
TELEPHONE ........: (4(18)666
FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- --�-------- ---------- ---------- ----------
BTEMP FLAT RATE 1.00 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
TOTAL PERMIT : . 102.89 0.00 102.89 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 102.89 #387
---------------
TOTAL RECEIPT : 102.89
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
Community Development
� �� 10300 Torre Avenue
�` �:��• - Cupertino CA 95014
Telephone (408) 777-3228
C(TY OF Fax (408) 777-3333
';UPEi�TINO
Buildin De artment
JOB ADDRESS: PERMIT #
s -� �� ,� �- � � �, a �� � o � � � y
OWNER'S NAME: �l,A w� i N E-t L PHONE # D� -- Z� 3-- b o
GENERAL CONTRACTOR: ` �j k � �,�5 FAX #
��a3939
I am not using any subcontractors:
Si �;nature Date
Please check a licable subcontractors and com��lete the followin information:
SUBCONTRACTOR BUSIl`JESS 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
. l � r �� � — � � .-� � ,.— Zt3 G' �Z
�
Owner/Contractor Signature Date