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CITY OF CUPERTINO r 1
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMITNO.
10600 JOHANSEN DR TBD — TO BE DETERMINED 07010046
OWNER'S NAME: PERMIT 15SUE DATE
WEN PING LIU 02/26/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 a
p AT
LICENSED CONTRACTOR'S DECLARION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMO OF S FDWL
y in full force and e (�t q('2-'' '?
? Licen Class Lic.A
p Date Contractor 4 Gy
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
U
t-N" Licensed Professional
3
,S OWNER-BUILDER DECLARATION
c g 1 hereby affirm that I am exempt from the Contractors License Law for the
}.Q following reason.(Section 703 1.5,Business and Professions Code:Any city or county
,
fug which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
s e that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
• (commencing with Section 70D0)of Division 3 of the Business and Professions Code)or $10000 10000
F 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 t Number Occupancy Type
not more than five hundred dollars(5500). 37536013
U U
❑1,as owner of the property,or my employees with wages az their sole,compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Busirvss Required Ins ections
and Professions Code:The Contractor's License Law docs not apply to an owner of fl P
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 year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License law.
❑I sin exempt under Sec. ,B&P C for this reason
Owner_ Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑I have and will maintain a Certificateof Consent to self-insure:for Workers Compen-
sation,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 Workers Compensation Insurance,az required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. - -
My Workers Compensation Insurance carrier and Policy number ant..:: ( _ 4
Carrier.Sf kf+C FVK Policy No.:16 7-4 1�1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ono hundred dollars(S 100)
or los.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
+e—+ 1 hereby affirm that there is a construction lending agency for the performance of
: ' the work for which this permit is issued(Ser.3097,Civ.C.)
Lenders Name
Z Lenders Address
Q 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 w
U building eonswetion.and hereby auihorirn representatives of this city to enter upon the
y W above-mentioned property for inspection purposes.
y �y (We,)agree to save,indemnify and keep harmless the City of Cupertino against
y Cel 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 WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
� Re-roofs
Signature of Appli nurser Date
--
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle,hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)9 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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 az defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have read the hazardous materials requirements under Chapicr6.95 of the Califor-
nia Health&SafctyCodc.Sections 25505.25533and 25534.1understand thatilthc building
docs not curt dy have a tenant that it is my responsibility to notify the occupant of the
rcqui nus w ich must be m I prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
O or autho'.cd agentarc'
All roof coverings to be Class "B" or better
CITY OF CUPERTINO
DEMO
CUPERTINO PERMIT APPLICATION FORM
APN# -3-15 y 3 r 13 Date:
Building Address:
r .r�i�
Owner's Name: Phone k
Z,-^ IF 9" L (H a r2l--7644
Contractor: T I License#:
s vf'7o 9A
Contact: a I Phone#:
Applicant/Contract
Building Permit Info: /
Bldg Elect ✓ Plumb ✓ Mech
Job Description: to o
Residential: (DCommercial:
Sq.Ft. Flo Area: t $/Sq.Ft.:
Architect/Enineer: Valuation:
Ila• /Q, cJtlz>,
Type of Construction: k Occupanc Group:
ovl
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPINO
Building Department
JOB ADDRESS- PERMIT #
LQ6ao a�� 5� p r � -4-1) 67 D/0 0(
OWNER'S NAME: (W eAA P i -.L PHONE
GENERAL CONTRACTOR jiv- 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/C tra for Signature Date