B-2016-1685CITY OF CUPERTINO BUILDING PERMIT'
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1685
21599 EDWARD WAY CUPERTINO, CA 95014-4764
XIANG SHANG LI
(356 19 008)
CUPERTINO, CA 95014
OWNER'S NAME: CHIUKAREN KO-YUEN
DATE ISSUED: 04104/2016
OWNER'S PHONE: 5108869866
PHONE NO: (408) 828-2242
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO
License Class -110 Lie. #Z843II7
X BLDG X ELECT
Contractor XIANG SHANG LI Date 09/30/2016
—PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
I hereby affirm that I am licensed under the provisions
JOB DESCRIPTION:
of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business & Professions Code and that
UPGRADE (E) 100 AMP MAIN SERVICE PANEL TO (N) 200 AMP PANEL
my license is in full force and effect.
I hereby affirm under penalty of perjury one of the
following two declarations:
r. I have and will maintain a certificate of
consent to self -insure for Worker's
S Ft Floor Area:
q'
Valuation: $6000.00
Compensation, as provided for by Section
3700 of the Labor Code, for the performance
APN Number:
Occupancy Type:
of the work for which this permit is issued.
' 2. I have and will maintain Worker's
356.19 008 -
L Compensation Insurance, as provided for by
J Section 3700 of the Labor Code, for the
performance of the work for which this permit
PERMIT EXPIRES IF WORK IS NOT STARTED'
is issued.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION
180 DAYS FROM LAST CALLED INSPECTION.
I certify that I have read this application and
state that the above information is correct. 1
agree to comply with all city and county
Issued by: PAUL O'SULLIVANf
ordinances and state laws relating to building
Dater 04/04/2016
construction, and hereby authorize
representatives of this city to enter upon the
RE -ROOFS:
above mentioned property for Inspection
purposes. (We) agree to save indemnify and
All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an
keep harmless the City of Cupertino against
inspection, I agree to remove all new materials for inspection.
liabilities, judgments, costs, and expenses
which may accrue against said City in
Signature of Applicant:
consequence of the granting of this permit.
Date: 04/04/2016
Additionally, the applicant understands and
will comply with all non -point source
regulations per the Cupertino Municipal Code,
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Section 9.18._
r
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code,
Signature
Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter
9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally,
Date 04/04/2016
should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air
OWNER -BUILDER DECLARATION
Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
I hereby affirm that I am exempt from the
f
Contractor's License Law for one of the following two
Owner or authorized agent:
g
reasons:
i. I, as owner of the property, or my employees
_!
Date: 04/04/2016
with wages as their sole compensation, will do
TR TI LE D E Y
I hereby affirm that there is a construction lending agency for the performance of work's for which this
the work, and the structure is not intended or
permit is issued (Sec. 3097, Civ C.)
offered for sale (Sec.7044, Business &
Lender's Name
Professions Code)
z. I, as owner of the property, am exclusively
Lender's Address
contracting with licensed contractors to
construct the project (Sec.7044, Business &
ARCHITECT'S DECLARATION
Professions Code).
I understand my plans shall be used as public records.
I hereby affirm under penalty of perjury one of the
Licensed Professional
following three declarations:
1, i have and will maintain a Certificate of
Consent to self -insure for Worker's
GENERAL PERMIT APPLICATION 5,9DI(o - 168.5
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinaCa)cupertino.org
MEP
MISC
❑PLUMBING ❑MECHANICAL IXELECTRICAL_ ❑MISCELLANEOUS
PROJECT ADDRESS rlt � Ct 11 1 APN #
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CONTACT NAME PHONE E-MAIL
STREET ADDRESS e� CITY, STATE, ZIP FAX
[71 OWNER ElOWNER-BUH,DER ❑ OWNER AGENT I� ocTGCTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
e7�J' �t'Vv p^LI SE TYPE BUS.
LIC #`sCONTRACTORNAME LICENSENUMBER7JZT,3Q%
COMPANY NAME�06orCll-13' FAX
STREETADDRESS i - , j J , e CITY, STATE, ZIP V �y kV % /�, G tr P PHONE /`i F ?QT Q
ARCHITECT/ENGINEER NAME (J UV
(x �(V I LICENSE NUMBER L vd' \ 6 BUS. LI'C�^� Q
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF ❑ SPD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WHALAND ❑ YES PROJECT IN ❑ YES. IS THE BLDG AN ❑ YES
BUILDING: ❑ COMMERCIAL URBAN EQTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO.
DESCRIPTION OF WORK �'® (� n l h ) G
TOTAL VALUATION: RECEiUED BY -
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prof erty 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
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified/nefied property for inspection purposes.
Signature of Applicant/Agent: `nAo 3 ea la Date:21
SUPPLEMENTAL ORMATION REQUIRED o> ii& USS oN% ,
OVER'i`HE COTJNTER
�� ❑ EXP7iESS � �'
A,_ 10 STANDARD
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77777-7-77777,g
MEPMiscApp_2011.doc revised 06121111