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CITY OF CUPERTINO
BUILDING DIVISION PETim
BUILDING ADDRESS: KENNY FU PERMIT NO.06110092
21569 WOODBURY D
OWNER'S NAME: PERMIT ISSUE DATE
KENNY FU
PHONE: SANrTARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 0
Z LICENSED CONTRACTOR'S DECLARATION
Description
Descr
p 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JoP
U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
N in full force and effCCL REVISION: FOUNDATION AND FOOTING
? License Class Lic.N
)(Z Date Contractor ORIGINAL PERMIT 406070163
,.r ARCHITECTS DECLARATION
,.r 1 understand my plans shall he used as public records
U'
i�
Licensed Professional
,< OWNER-BUILDER DECLARATION
f I hereby affirm that I am exempt from the Contractor's License Law for the
0 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 strvctum
prior to its issuance,also requires the applicant for such permit to file a signed statement
t< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Vall idnl 17 3
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
._ 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 APN Number Occupancy Type
not more than five hundred dollars(5500). 32645047 . 00
p y yp
❑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 forsale(Sec.7044,Business
and Profusions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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.),
!,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's 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 Contractor's
License Law.
❑I am exempt uhder Sec ,B&P C for this reason
Owner Date '� q
RKER'S COMP� A DECLARATION
I hereby under penalty of perjury one of the following decl ons.
❑1 have and will maintain a Certificate of Consent to self-insurc for Worker's Compen-
sation,as provided for by Sccdon 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 required by Sccdon
370D 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 am:
Carrier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(5100)
or less.)
I ccnify that in the performance of the work for which this permit is issued,I shall not
employ any person in an) annerso as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICA .1 cr making thi Ccni teats of Exemption,you should
become subject to the W rk 's Compensation provisions of the tabor Code,you must
,Z forthwith comply with s 2RUCTION
visions or this permit shall be deemed revoked.
C)
LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
i > the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Z Lender's Address
I Q 1 certify that I have read this application and state that the above information is
.--t Correa I agree to comply with all city and county ordinances and state laws relating to
jU building construction.and hereby authorize representatives of this city to enter upon the
t W ahavc-mentioned property for inspection purposes.
ty (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,jud ments,costs and expenses which may in anyway accrue against said City
Z in consequent of the granting of th)s perr��rr it '
'— APPLICANT UNDERSTANDS A WI!COMPLY WITH,Ad NON-POINT Issued by: Date
SOURCE R ULATIONS,
Signature oftplificant
licanVContractor Re-roofs
D tcHAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wil) or future building occupant store or handle hazardous materia
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,SectionY25532(a)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant okNo
re building occupant use equipment or deviceswhich 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 (t�Nu
1 have mad the hazard(ms terials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not c oily have a tenant,that it is my responsibility to notif "cupant of the
requircmc which must be met prior w)ss c of a Certific Occupan . IgrlatUre of Applicant Date
Owner orah rued agent Da
L J V All roof coverings to be Class "B" or better
CITY OF CUPERTIN(* 0L01 1 d()qg
CIN OF
CUPEI�T9N® PERMIT APPLICATION FORM
O,5'o 7a/
APN# Date: /
111 �l 0 V
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone #:
Contractor: v i3 License #:
Contact: S Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
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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OTY OF CUPERTINO 0
CI OF PERMIT APPLICATION FORINT
CUP KrINO
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
BPSPRINK Lawn SprinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFLRN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l 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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