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CITY OF CUPERTINO
BUILDING DIVISION PERMITCON S����
BUILDING ADDRESS: PERMIT NO.
104-18 PRUNE. TRFF T,A —
OWNER'S NAME: PERMIT LSSUE DATE
LIU TSUNG—TIEN ET AL 01/02/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ZLICENSED CONTRACTOR'S DECLARATION
o Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
w with Section 7000)of Division 3 of the Business and ProfessiunsCodc,and my license is 550 ' ADDITION TO• GUEST BEDROOM SUITE, KITCHEN,
a in full force and effect.
Z_ License Class Lic.a NOOK & SKYLIGHT
p Date Contractor
ARCHITECTS DECLARATION
F I understand my plans shall be used as public records
U _..... _._....-_ ..-..... _.._.......,,,_ ._...._.._ ......_.._ _.... -........
Licensed Professional
a OWNER-BUILDER DECLARATION
� I hereby affirm that I am exempt from the Contractor's License Law for the
IIS
10 following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve.demolish,or repair any structure
ti prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor AreaValuation
Oo (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $11 03
.°2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 31633081 , �Number Occupancy Type
not more than five hundred dollars($500).
❑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,Business Required In CCU OPS -
and Professions Code:The Contractor's License Law docs not apply to an owner of -
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 yeas of completion,the owner- _
builder will have the burden of proving that he did not build or improve for purpose of
ti
sale.). "�
❑1,asowner o[the property.am exclusively-contracting with licensed contractors toconstruct the project(Sec.7044,Business and Profusions Code:)The Contractor's Li-
cense law docs not apply to an owner of property who builds or improves thereon,and. (tit./
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's /^'�/ --
License Law.-
0
❑I am exempt under Sec. ,B&P C for this reasons'
Owner -f. .. Dale / -a D
W RKER'S COMPENSATION DECLARATION
1 re firm under penalty of perjury one of the following declarations: ,.
❑I have and will maintain a.Ccniftcate of Consent to self-insure for Worker's Compen-
cation,as provided for by Section 3700 of the Labor Code,for the performance of the.
work for which this permit.is issued. .. -.
F1`1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompletcd if the permit is forone hundred dollars($1110)
or less.)
1 ccnifv that in the perfotmance.pf the work for which this permit is issued,1 shall not
crriploy,any person in any manncrso as to be c subject to the Workers Compensatio
Laws o[Caliromia.Da
Applicant ° --
NOTICE TO ,If,after making this Ce I twit of Exemption,roti ould. .
become sub'ct the orkcr's Compensation provisions of the Labor Code',
Z forth.i(hcolKply with such provisions or this permit shall be deemed revok
C/)
V) CONSTRUCTION LENDING AGENCY-
'-+ � 1 hereby affirm that(here is a construction lending agcncy.tor a performance u[.
the work for which this permit is issued(Sec.3097,Civ.C.) 'r✓°
A Lender's Name
Lender's Address
C) 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 ordinances and state laws relating to
Ubuilding eonstryclion,and hereby authorimrcprescmativrs o[.this city to p»ter,upon the _
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and.keep harmlcss:ihe City of Cupertino against
V) liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
'•� APPLICANT UNDERSTANDS AND.WJJ..L CO PLY WITH ALL ON-POINT Issued by: Date r
SOURCE RE UL ONS.
I - f :;—Io Re-roofs
Signature of.A Iicant ontraetor Dale
AZARDOUS MATERIALS DISCLOSURE Type Of ROOF
the alf liwnt or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Codc.Chapter.9.12.and'thc Health and Safety
Code',Section 25532(x)? - �� ` -
r-1 Yes "d�'" All roofs shall be inspected prior to any roofing material being installed.
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 V .
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafelyCode,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant that it is responslhil ity to noufy the occupant of the'
rcquircments in ch must be met p' r to'suaoce a rtiecatc of occup 7y. Signature of Applicant Date
Ow authorize gem nate All roof coverings to be Class "B"or better
{
t
WITY OF CUPERTIN(*
CUPEI�fINO PERMIT APPLICATION FORM
APN# Date:
-3 l(= -- -3 3— S 0 6
Building Address: Mailing Address (if different from building address):
(0-4-3 7-"PLE-E-
Owner's Name: Phone#:
My. M�-Q L i u 1--409) "6— -79 8�
Contractor: License #:
T, 8, J>
Contact: Phone:(4419 - 4 Cupertino Business License#:
T:1ev Fax: l4��946-`rao
Building Permit Info:
Bldg r Elect 1z Plumb Mech
Job Description: ic)%W. 6t v vd+- R4--A room 9 uZ4-K ,
Residential V t M o o i c..• s k.rt i+e Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
,;;Da. 4- S-6 c •4-,r0. e
Cost of Project: Occupancy Group:
a C ;?---3
Type ofCo struct}on: Please check this box if the project is a
�J second-story addition: ❑
Project Size: Standard Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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OITY OF CUPERTINO
CUPEkTINO
PERMIT APPLICATION FORM �
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL - Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRNK Lawn S rin er/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/After Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFLTRNOV Relo Furnace> 1 OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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