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1CITY OF F11JJ1ulV E 11 APP L ECATEO V FORM
CUPEVI NO
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Date: j D Z
Building Address:
/ oq �cD r-a�co- -,L�r .
Owner's Name: <�)�uuun p i n m,n Phone#:
Contractor: License#:
Contact: Phone #:
Applicant/Contractor: Fax#:
uil ' g Permit Info;
Bld (Elec) QIU Cech)
Description: say ��6rv6 rvo•'►l, L--,e 1-f t-,M L&� „Cbu� , ear ACQ
Residential: U roma e=i al
Sq.Ft. Floor Area: $/Sq.Ft.:
el(- = I01AR �� ; lA (3-1 J_= 2499 4120
c ite ngineer: Valuat
CIX a.1 N Ai1,J 11\ r z�k
Type of Construction: ,�� Occup c Gro ,
Quantity Fee ID Fee Description ]Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC 1000 Elec 600V<= 1000A ELECTRICAL
BELEC 1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
B EI,'4 ERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BII\IVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1of3 I � 60 �
TY OF
CII BUILDING DIVISION 7�T(�7�� CONTRACTOR ffN FO1[BI� AM'°�Ya
1C 1GJL�"l�'ll ^"
B iLDING ADDRESS: PERMIT NO.
0980 BARRANCA DR 02050189
G�y iWER.AN & MINMIN QIN 05/30/2002
PHONE:
W 1V
APPLICATION
/ SANITARY NO. CONTROL NO.
t is O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
V BLDG ELECT PLUMB MECH
H« L_I I_J
ti LICENSED CONTRACTOR'S DECLARATION
Z Z y? Job Description
O Z_,, 1 hereby affirm that I am licensed under p visions of Chapter 9(commencing ADD 1450 S Q.F T.
E-rn[-u with Section 7 )of Division 3 of the Business$W Professions Code.and my license
<Y E.4 is it fulland act, n
im < License ss Lic.N ! 0
O a 0 DCont r L
yat ARCHITECT'S DECL ION
[- O 1 understan fans shall be us as public records
rata O riaefised Prof Tonal
a a R-
m O BLTLDER DECLARATION
tart=sn I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason.(Section 703 1.5,Business and Professions Code:Any city or county 2 0 0 0 0 O
FZ-0 which requires a permit to construct,alter,improve,demolish,or repair any structure
LU 3- Prior to its issuance,also requires the applicant for such perm;[to file a signed statement Valuation
that he is licensed pursdant to the provisions of the Contractors Licensc Law(Chapter 9
r
(commencing:with Section 7000)of Division 3 0(the Business and Professions Cody ` 3 2�0�.,'L�*` 0�T..�a a
or that`he'is ezempl therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty'
sof normom than five hundred dollars($500). 101 AP-N PEAT I ON Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation, 102_ — PIERS _
'Will do'the work,and the structure'is not intended or offered for stile(Sec.7044, 103 — UFER Required Inspections
Business and Professions Code:The Contractor's License Law does not apply to an '
owner of property Who builds or improves thereon,and who does such work himself 104 — REBAR
or through his own employees.provided that such improvements are not intended or rye Sr+
offeied for sale.1f,however,the building or improvement is sold within one year of 105 — ANCHOR BOLTS
'completion,the owner-builder will have the burden of proving that he did not build or
improve for purpose of sale.). 106 — SEWER & WATER
. 202 — UNDERFLOOR PLUMBING "
." •fJ,l,az�owner o(the property,am exclusively cmmraaing with licensed contractors ro -
construct the project(Sm.7044,Business and Professions Code:)The Contractors 203 — UNDERFLOOR MECHANICAL
-. - License Law does not apply to an owner of property who builds or improves thereon,;
and who contracts.for such project with a.contracror(s)-licensed pursuant to the 204 '—' UNDERFLOOR 'FRAME
C�ittractors License Law. .
I am exempt under Sec. ' ,'13&P C for this reason 2 0 5 — UNDERFLOOR' I N SULAT ION
Date 301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
I hereby affirm under penalty of peijury one of the following declarations: 303 — ROUGH ME CHAN I CAL
-�- nave and•w;ll mairitaid a Certificate of Consent to self-insure for Worker's304 — ROUGH ELECTRICAL
.Compensation, az provided for by Section 3700 of the Labor Code, for the
'performance of the work for which this permit is issued. 3 05 — FRAME
❑1 have'and will maintain Wdrker's'Compensation insurance,as required by Section 306 — HOLDOWNS
3.700 of the Labor Code,for the performance of the work for which this permit is 307 — INSULATION
_ issued.My Worker's Compensation Insurance•earier and Policy number are:'
30 SHEE ROCK
PolicCerriec CERTIFICATION OF EXEMPTION FROM'WORKER$' '3 0 5' "-.'EXTERIOR LATH"
COMPENSATION INSURANCE' - 3 1,0 INTER"I-OR -LATH
•(This section need not be completed if the permit is for one hundred dollars 311 — SCRATCH COAT -
(SI00)orles:.) 313- — ROOF NAIL
t certify that in the performance oRhe worl•(or hich this permit is issued,l
shall not empl y any pprsom i ny manner so as by�`9r 5�n�eej rte workers
501 — F I NAL ELECTRICAL ENERGY
Compensatiti ws of Ca a.Da[s' << ! 5 0 2 —. FINAL F I NAL PLUMBING .ENERGY
A !;Cant .-
ICE TOAPPLIC .lf, tel' -ing this Certifcate of Exemption,you should
503 — F I NAL MECHANICAL ENERGY
come subject,to the er's rape cation pmvisions o(the labor Code,you must
00 forthwith rnmply with such prov,s;ons or this permit span be aeemea revoked. 504 — F I NAL BUILDING,.ENERGY,,
CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL'
[herc6y affirm that there is a construction lending agency for the performance
-,of Ae
-,Lender's
which this permit is issued(Sea 3097,civ.C.) _ _ 506 = GAS TEST
Lender's Address. 507 FINAL PLUMBING.
0 ® 50 FINAL MECHANICAL
� .I cenify.that[have read this application and state that the above information is
rpt correct.I agree 19..comply with all city'and county ordinances and state laws relating 5 INAL G E
® � to building construction,and hereby authorize representatives of this city to enter upon 5 0 — INAL P NG
the above-mentioned property for inspection purposes.
(We)agree to save.mdemni fy and keep harmless the City of Cupertino against 51 — INAL RKS
U0 liabilities,judgments,costs and expenses which may in any way accrue against said r
City in consequence of the granting of this permit. l
APPLICANT UNDERSTANDS AND WILL COMPLY WITHALNON O]INT'
_ SOUR REc(:LAr S. Z Issued by., Date
5- atureofAp nqi!orjrpctorDate - Re-roofs
HA DOUS ATERIALS DISCLOS
Will the applicant future building occupant store or handle hazardous material T�pe of Roof
-• - - az defined by the Gupertin°Municipal Code.Chapter 9.12,and the Health and Safety
CoCp,Secdon 25532(x)? '
❑Yes 1 No All roofs,shall be inspected prior to any roofing material being.installed. .
Will the applicant or future building occupant use equipment ordevices which If a roof is installed without first obtaining an inspection;I-agree to remove
emit hazardous air contaminants az fined by the Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
Oyes "° all non-point source regulations.
1 have mad the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
;;f ttietbuilding does not currently have a tenant,that it is my responsibility to notify the
cupant of the requirements which must be met prior to issuance of a Certificate of
up y- Signature of Applicant Date
Owner on authoriz agen't gate All roof coverings to be Class"B"or better '
OFFICE