08070149 CITY OFCUPERTINO
BUILDING DIVISION PER C�11�IT.�RAiCTOR I1V�Ii'U�RMA.TI; N.
BUILDING DRESS: PERMIT NO.
0 SAN FERNANDO CT TBD — TO BE DETERMINED 08070149
NER'S NAME: PERMIT ISSUE DATE
AhEX ANO NUEVO & LILY DONG 09/04/2008
PHONE SANITARY NO. 'CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
E 0
O o LICENSED CONiRACIOWS DECLARATION IOb Description
1 berebY affirm that 1 w IfxNed under pmvis ons of Otspmr 9(commencing
_x with Scction 70001 of DiviaonSof dm Buanea and Professions Code,and my licenmu DEMO SFDWL 1100SQ
< in full forte and effect.
j b= Lice Clan
n F p Dans Cantrutm
egq7W ARCHr1ECTS DECLARATION
1 undersand my plans shill be umd on;public mcards
W U
I;
Loa Lkensed professional
OWNER-BUILDER DECLARATION -
'� f 1 kmby ilium that I am nsompt Into the Contractors Uccr m law for rhe
OO following indoor.(Sccdon 7W 1.5.Buatw and PNfevims Coda:Any city or..all
C
S V which OnIm a•pcmrit to emmruct,Aw.improv.nnmolisr,or inpAr any atnteam
u Z y prior m its issuance,also require the applicant for such permit to file a signed staliment
<
that Mulmeracdpiamonauomnpmviaonsrfthan Coo.'e,uzNeLaw(Chapw9 Sq.FL Floor Area Valuation
F O (commencing with Sntion7000)of Division 3 of the Business and Prof ions Cade)or $10000
Jtu he b exempt therefrom and the bilis for the alleged exemption Any Halation of
Section 7031.5 by dory.,11coat far a permit mbjccu roc applicant to a civil I-All or Number Occupancy Type
rrm mum man Bee hundred dollars(S-10010. 35712011
wi Luownerofine lamAnscair is employee withwgeauale(solecompensation,
and dathework,sedmeshe Con IsctotinI I ocowtoTarsale(Sat.TMJ.BoAmoss
ow—of
and erly wh oba Code:The Comncwh Liana Low dans rat apply m an oww of _ Required Inspections
onamwImbufdsaintpmts Jh impraMwho doeasunswithimselfairthNm his
ownempbye Wildal or imatsuch imis sold it ve not inaeededocoRered fon,aka,
however,the ow on fo or d.of pr vit is halt within arc yw or completion.the oww-
builder will haw Jre burden of proving Out on,did int bulid or improv for purpom of
dole.). '. . ..
1.n owrcr of the pmpmY,w extluiwntr
ly coacting wm
with ;--..d cortracs
donut the pm)ect(Sec.70th.Busiws and!ProfmadoN Cade:)The Contracmfs Li-
ctew law docs not apply to an owNr of property who builds or improve memos and
who contracts for such projects with a eamractor(s)licensed pontoons in circ Cmaraomra
Lieeve law.
❑Ion oempt.0.sm ,B&P C for mu moon
` Das /VC
WORT - 'S ATIQN DECLARATION
1 hembY+Hint under pcda tY of perjury ane of inn following dalanuons:
0 hove and will maintain a Ce+tiOomor Commit to elf-loomfaWarteraCampen-
am .at poviGG for by Section 37011 Of the Latin,Cade.foc that pedormanm or the
work for which this permit is issued.
0 1 haw and will maintain Workers Compensation INunrue,as inquired by Section
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. '
My Workers Componsomm Inmrance canis and Polity number doe:
Canicr Polky No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aectimn reed not v complemd if Iv pernk it focarc huriAtd dollen(SIM)
or kis)
I snit that in the performs.of the fork fur which this per is is issued.)shall rut
employ anypeson in any menrmrspu g become wb)ea m the workcts'CompeNaOon
Laws of Callfomia.Das-— 1dt""/ /Nf'�� X
Applicant '��
NOTICE TO APPLICANT: .a r maW g this Cerificam of Eacmpcon,you Arabia
venae subject m the W s Cmnpc 'on pindwands of the labor Cann,you mum
0 forthwith comply with cash proviaau a murm
permit shall v dame!awe
kd.
z y CONSTRUCTION LENDING AGENCY
[—i ^ ivinby aRmt mat themuacorutroctinn lending agemy far Jin perfortnana of
the wort for which this permit is issund(Soc.3097.civ.C.)
Q landnls Name
z hinders Address
V Q 1 mNfy oras 1 haw rod thio application uW sum Nat me above inf000tiun u
C4 Uconect.1 agree m i anply vim ill city sad c pros ou wiles and sou laws rotating e
AbowngcansaudanlsA vinby auth.purposescnudw of mu city mcnwupnn lK
sMw-mentimmd popery for nton ly an purposes
(We)ifora m aw,indemnify and keep haroku Jct City of Cupertino agarm
IV) Ifabmmos iarict cns,eosu add upeNuwhich may in any way mom agilw and City
V z A APPLICANT
of UNDERSTANDS
of this permit. J '
^ APPLICANT UNDERSTANDS AND WI L OMPLY TH ALL NON-POINT Issued by: Date �� J
SOURCE REGULATION$.�
Date
Re-roofs
Signuum of ApplianUContrxtar
HAZARDOUS 6ATEJUALS DI OSURE Type of Roof
ndil by
CicantosToon bpalCoaaupmta m Nndk huudaand Wert
u nnfircd pry du 32(a)?rw Murritipal Cade.Clnpmr I3,and Ju Nolth and WetY
.section 15x33(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ye f7i�No
�a If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or rutuin Willing occupancy Aequipment air lcvices which P g
emit h➢andnns air cmuminsnu u Je6ned hY the Bay Arca Air Quality Managcmcns all new materials for inspection.
Disrict7
❑Ye 'ANO
I haw mail the huxdwa mscrial mquirtmerts under Chopw6.95 ofthe Ca fon
nu Health&Safety Codc,Salons 35505,35533 and 75534.1 un arsund thatifthe building
Jas not carnally haw a tenant than it u my resporwhility to notify me acupam of du
raquimmenuwhk; tpriorm' mort3cmpanry.
Signature of Applicant Date
Owmruraumnd<dagenl Dam All roof coverings to be Class'W'or better
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT R INFU�tMtTI®1Y.
BUILDING ADDRESS: PERMIT N0.
?080 SAN FERNANDO CT TBD — TO BE DETERMINED 08070149
OWNER'S NAME: PERMIT MUE DATE
A!�PX ANO NUEVO & LILY DON G 09/04/2008
PHONE: - SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTOR'S DECLARATION
U P I hereby affirm that I am licensed under provisions of Chapter 9(commcncing lob Description
Z awith Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMO S FDWL 1 1 0 0 S Q
in full force and effeeL
j Z License Class Lic.it
Date Contractor
ARCHITECT'S DECLARATION
wU I understand my plans shall be used as public records
,a
O y Licensed Professional
fin OWNER-BUILDER DECLARATION
a f 1 hereby affirm that I am exempt from the Contractors License Law for the
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y 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 Area Valuation
SEC t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $10000
Ll R.. 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 ofNumber
not more than five hundred dollars(s500). 3 5 712 011 `V( Occupancy P Y Type
❑f,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
and Professions Code:The Contractors 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 We.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.).
If I,as owner of the property,am exclusively contracting with licensed contractors to
onstruct the project(See.7044,Business and Professions Code:)The Contractor's U-
cense Law docs 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 uDder Sec N B&P C for this reason
Owner Date
WORE'° 'S-CBI E ATIQN DECLARATION
I hereby affirm un er penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to selPinsum 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 Worker's 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 be completed if the permit is for one hundred dollars(5100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner sVp cc me u jeci to the Workers Compensation
Laws of Caliromia.n_
ate a
Applicant
NOTICE TO APPLICANT:1,a cr maki g this Ccniftcatc of Exemption,you should
become subject in the Workers Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked. -
zz '- CONSTRUCTION LENDING AGENCY
—
1 hereby affirm that there is a construction lending agency for the performance of
CYi , the work for which this permit is issued(See.3097,Civ.C.)
aQ Lender's Name
Z Lcndees Address
U Q 1 certify that I have read this application and state that the above information is
Iy— corecL I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
mFr CA 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 REGULXnONSr
Re-roofs
Signature of ApplicantlConuactor _ Date
HAZARDOUS 16ATERIALS Dl LOSURE Type of Roof
Will the applicant or future:building occupant st or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 912,and the Health and Safety
Code.Section 2553Z(a)?
Yes All roofs shall be inspected prior to any roofing material being installed.
❑ 17�No
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 ANo
f have read Ute hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand thatif the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
requirements which must met prior to issuan o Cc ' to of Occupancy. Signature of Applicant Date
Owner or authorized ager Date g ass
All roof coverings to be Cl °'�}'`or better
s � �T'
(9
CI'T'Y OF CUPERTINO
DEMO
CUPEKFINO PERMIT APPLICATION FORM
APN# 57 �-
A . -e op/ v Date:
Building Address: It&0 949 r
Mailing Address (if different from building address):
Owner's Name: Phone:
�", 0(k0,'(P _AW& P/�155 7®(v 07-44
Contractor: Phone
Fax:
Contractor License #:
Cupertino Business License #:
Contact: Phone:VILW ,�� �
Fax: ( ��
Residential Sq Footage 00 Commercial ❑ Sq Footage
Job Description:
Valuation:
�- 0 D
Project Size: Express ❑ Standard K��Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index. q
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEM
1BSEISMICRE Seismic Residential B
Revised 6/16/08
CITY OF CUPERTINO
DEMO
CUPEVI INO PERMIT APPLICATION FORM
Quantity Fee IT) Fee Description Fee Group Permit Type
1DEMOCOM Demo-Commercial B 1COMML-DEM
1DEMOPCOM Pool Demo Commercial B 1CPOOL-DEM
IBSEISMICOM Seismic Commercial B
1 BUSLIC Business License B
Revised 6/16/08
1