05120068 CITY OF CUPERTINO s I `'
BUILDING DIVISION PEgNUT C0NTRACT091NF'0RM ON ,7
BUILDING ADDRESS: YUN -TE LAI PERMIT NO.05120068
1455 ASTER LN
OWNERS NAME: - PERMI7I55UEDATE
YUNG-TE LAI 12/13/2005
NE:
SANTEARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMrf INFO
BIRO ELECT PLUMB MECH
0 0 0
iloo LICENSED C'ONTRACTOR'S DECLARATION Job Descri tion
�+F I bucbY affirm Nut 1 am Boozed Undo,Nnviiio.of Carpo 9(mmmcnclnr P
W
nwfollI nton!n!o)of Divirion3Mihc Buannf u,d Rafutima CoOc.Wmyllcwcic
33 .W aat a REPAIR GAS LINE (INTER. )
5
^q Da¢ CaS DEC,
7W an."I o o o DECLARATION
#�< IuMcrvanJ my Nlana WJl be urdupubue na«ds
J U
Lkrned Pm(caioval .
N
f. I nn BUIIDERDECLARATION
5 1 hc+cby aRrm ut am 15oacmpt Tran ft PO Cmu.nafa Ikcuc 1y,w for tK
n o folloainr n n.(Smrion]07 ,BtWoPm
n
s and fetiou Cock:Any dtY or manly
$ vbkh rt .bu•NMit 10 cotfYruc4 alta,iro m .Ecmtdeh,or rtPak any ewcturc $300
Prior to iu iattana.abv n tdna da,Imtkanv for soh xMit to fk a sir«d R.Tcwnt
Ex< matKella.dpu,.towcP,n.;si..ada,cnn ,U.Lal (Chap.,9 Sq.Ft. Floor Area Valuation
yF$ ftanmcmne with Section]000)ND on 3 o the ll i am Profcasia,u Ctde)0,
.- Thu h e e MN Nuef).and The bada,for tM allerOf cxmptioa Any MDhLdon of
sawn 7071.5byany.pplicau r«.NOMI aubjea,the.Wli WaO 1pally of r Occupancy Type
o«Mort than foe Madrid dales(5500}
❑1.u awucr of vk pmpury,«MY emPlvym wiN vrn u the'v sok mnpemvoe,
anddorite w..stilt TboIC. anotintended«Metedt— (ser.10.4.Butitrn
and Ptare.dae.coos The canuanoh Ligate Iia ma n«.Ppy to..awttO or Required Inspections
pia W 5Y woo bnlN«llnlaaMJ thump,sad who hu s«h Mak Yimsdf«tlTmorb he
owe Ooplayca,lding MdthatatshImptmememaart tat In¢a «hued r«auk If.
Wilda,,viebvildinr«Irnptopn« .rola Wthin onelar of iro kfn.theta,of
buldcr wW hatc ver:b«ha or proWer that he die vat ddW«impmte f«T^Pox of /a as
ok.}
��Vbl}pi� 'NpOOp
1,a win a(tlx Nropeny,.M udoadv r c ibn5 avh tira.aed caneuuan b
EEOuvthe pm3m(Sec.1044.Buabtoa and Pofeaion Coh:)The ConuuMY.U
e I�w alto tt«apply W ao war W pnopcny,rbo balldu«improm themm,wd.
canuacu(«sub Pmjcna MN•mavacn«(u)Iatned quswM W stat CoavanaYa
n�Law. C' C 9.fl85
1, umtpt tmdcr 5M Zo,Vii.S ,I+�■ 1 yyy'''���444,,, B
ftry arr 13
ORKERS COMPFNSATy no DECLARATION
(/ BUIL I ON
I hemby dDtm tinder pwLLY M pujmy oto of Ne falb,vinr,wr.N.t,.,. RI�6D' It
xofmbytion3TftCda.foaI u Prorltld f«by Scotian 71(10 0(tK ichor ooh.f«ate pufowantt of Ne
work I.rhich tin.pewit I.ivuN.
❑1 lave and anti main,.;..W«krY.C«olxuatim Iwua.as rtgimN by section
3]00 of the Mbar Code,f«the N f«marce of the wart for which Ne NOMI la naiad
My W«ke r,Compeualeo lna a anis and Polky nomb,r arc:
Cantu: Policy Na:
CERTIFICATE OF UEMFTION FROM WORKERS
COMPENSATION INSURANCE
(The metkn Nod not be c Ploted iftbe NMI,Uf««,c hinhed Wart,(SIW)
«lass,)
I c N that in the pcfomuea of The work f«whkh dirt.Putnn U laved,I"I not
cmpby aM Pump in any memo an a{nk oep'tW the Worlom'Cvnpewtioo
I.awn of Callfomla Dau �3�I
Applkvuti
NOTICE TO APPLICANT:If,after nukinr this Ccniftrae(.t�.'noo,you thouH
bO«oe toir m to the Wer ,CorbNnaa i pmriaiou or de Labor,Code.yin must
.JZ roMw;th comply wnh,uch Ft Dos or We pctmita be daamdmrutrb
z(z) CONSTRUCTION LENDING AGENCY
H^` I hatmby affirm dw Nue is a mnwumlw kndinr ag Ny for the perfamun 9
a> vc wart in,which N4 N,MIt it iutrd(s«.wrl.CN.C.)
W Q undero Name
Z Laodee.Addnas
U O 1 cavfy that I baste rad dak appliotiaa and sate Wt the sbo.e itdOm.vm is
U. mnca 1 arta to comply Mitt W city ab county odi.,anal MW luwa mlulnr t-
o U building c«uu«ti9q an!hucby auth«ire minuontuitea ofthe city to"W upon the
alorc-menv«rd Property ra itar nap rrP
(WO.ria to ate,iedcmnify and kcaP harmless IN City N C.Nmno arainai
E'y IWifvec}odpanots.mnsand apc"a•ahich our in any stay acervo aralral said city
U Z in h.
APPL�IC NT UNDERSTANDS ND WILL COMPLY WRH ALL NON-POINT Issued by: Date
SOURCE,R�EGUI.V�ION�
/U t [ c �—a.--� 1 3�j� Re-roofs 4"1f i
SiyutWeoft'ppli—f ort aebr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the'Flmntor fnrtn boldingoampmu stow«haadlk ha>ardom matuiJ
u defutod by the Cupe Munck pd Code.Cbaper 9.12 and that Halth std Safety
odic.5eaioo M53$4)] All roofs shall be inspected prior to any roofing material being installed.
UttNo
Wil tiro appliant tar future b oudinr wMaxot=ryu lxrc or dc�whkh If a roof is installed without first obtaining an inspection,I agree to remove
i c,Oft hvandau air cmuminanwa u&5.4 by tK Bay Ata Air Quality Manarcmem all new materials for inspection.
District?
❑Ya AN,)
1 hart rt>J tk hanrdwa m.—+.t.taEnmtrcnu order Chaptr495 ofthe caldba-
ni.Ikal h SafayCodo.Soczu.25%5.25533and!]5534.1 Wtdumnd that ifft bwldinr
din n«cmunvy bate a trnanc vw it a my teolotmbility W.00dfy vo oanWnt nr the
mqutwnkh�ttteTPrior W�a�ttaar.cwl ofDmPar,,y Si� 124gnature of Applicant Date
ow« ma Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
aOF Fax(408)777-3333
,UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
SSS St6t� �;� t d S/2U D
OWNER'S NAME: a _Te Lci PHONE # 4�R z5;2-- K8 t
GENERAL CONTRACTOR FAX #
/ � 2
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
Ah 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/Contractor Signature Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. x All the work authorized by this permit
• B. _ A portion of the work
C _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
be— ffw—med
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of asuranre covering workers compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
ormed
........................................................................_...........................................................__.........._............_..................
I declare under penalty of perjury that the above is true and correct I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: � " Date: 2VI 3/ao=s
Job Address: (K 5 3 f Fe�— (.xy c ; C�;�z, ti o, C/f I S ,0( L'Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Deparlmerrt.
City of Cupertino Building Department
CITY f)F IM Torre Avenu
CUPEf�TINO '° ` '� 3
Dear Property Owner.
An application for a budding permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Budding permits are not required to be signed by property owners unless they are
personally performing their own work If your work is being performed by someone other than yourself,you
may protect yourself from possIlle liability if that person applies for the proper permit in his or her names
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan tb subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$2DO or more for the entire project,and such persons are not licensed as
contractors or subcontractors,then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensatior�
contributions.
These may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish the US. Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License.
Board in your community or at 1020 N Street,Sacramento, California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is return.ed.
Very truly yours,
Building Department,
City of Cupertino
Printed m Recycled Paper
CITY OF CUPERTINO
REPIPE/SEVERS/MAIN SERVICE
CUPEkTiNO PERMIT APPLICATION FORM
APN # 3(=, 4 Date: Z./)3/05
Building Address:
Owner's Name: �i Phone #: 2S 2 I o
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
SG vr¢-
BuildingPermitlnfo: 1�Qi<�nit� �tW� fL+J �hS �YtY (ty1?erior St
Bldg ❑ Elect ❑ Plumb
Job Description: '
Fix �ea k
Residential Commercial ❑
Cost of project:
3`'J
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repi eofFixtures PLUMBING
BPFIXTURE Pbl . Fixture . PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
3
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