05070174 CITY OF CUPERTINO4sat<s,rF'
BUILDING DIVISION PERMIT wtCONTRAGTORaINFORMATION
BUILDING ADDRESS: s PERMIT NO.
ANDY S CONSTRUCTION 05070174 '
W NAME: PERMIT ISSUE DATE
E: st fink{ssa y. h s _ r x, _ SANITARY NO. CONTROL NO.
; o
' A.(408) 7,35. O l l 1,; o ,' ,.
ARCHITECT/ENGINEER�+✓~7j�')h$"',,. i ^'S 9,y .M1"` d' y r,y v / As. -� BUILDING PERMIT INFO
L ELECT •' :PLUMB MEOCH
....«. Yz�'n..
500 't' LICENSED CONTRACTORS DECLARATION �f IOIJ 'eS i1 -
Lu C 'j I M cby affirm that I am littnud under provisions of Chapter 9(commencing P -
c with Scetimr70po)of Division Sof Me Busincornd Profcssioae Codc,and my license is
+'� imm�mmeand effect. TEMP POWER POLE
;�= License Class Lie.« 8 ��/— 2005
I Dam Cmametnr
ARCHrIECTSDECLARATION
1 Profen and my plata shall W used u public mcnrds tyro I p p
dpiSyU ®y L 'Wasp
Licensed Pmfczsional ,
3 OWNER-BUILDER DECLARATION
iy 1 hereby afGrmdhm I am exempt from the Conurteun's License Law for the
no following reason.Section?031.5,Business and Professions Code:Any city or county
5 m which requires a permit In consuuei,alter,improve,demolish,or repair any structure
poor m its issuance,also requires the applicant for such permit to file a signed statement
- < t
hal he.licenxdpurxuammtheprorisin� of Mecom,aemrsuaxLaw Sq.FL Floor Area Valuation
xFG (commencing with Section Trial of Division 3 of the Business and Profeuiom Code)or
i $ that he is exempt therefrom and Ile basis for Ne alleged exemption.Any violation of 1
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of _ .3APa g00 Occupancy Type
not more Nan Eve hundred dollars(5500),y
0 1,as owner crane property,of my employees with wages ss their sole eompensmon,
will dr the work and the awnum is not intended or offered for sale(Sec.7(t44,Burnam
and Pmfessiom Code:The Contactors License Law dors not apply to an owner or Required Inspections
progeny who Wilds or improves thereon,and who doessuch work himself orthrough his
awn cmployres,provided that such iroprovemenu are not in¢Med orolfered Waste.It,
however,Ne building or improvement is sold within one year of completion,the mamer-
builder will have the burden of proving that he did not Wild m improve for puryox of
sale.).
D I,as owner of the progeny.am�xclusivdy contracting with licensed contractors to
convect the project(Sec.7044,Business and Professions Code:)The Con meters Li
ecru law dors not apply b m owner of progeny who Wilds or improves thereon,and
who contracts for such projects with a eomsactor(s)licensed pursuant to the Contractor's
Liceaxtaw.;
❑lames tad See -^ i ' :B&PCforthtsmason _
r•,��}7} �Sr-r.f Dau t I5k i .1 r1. a { .._ ..
yrY sWORKERS COMPENS "0'.ECLARATION CM'^w• Y`•)• s "'{mss
I b41
in b n<Erm unidcr penalty of penury arc of the�oHr wing declarations:'w. ° -'
❑IE:ve and will maintain a Cenifiax of Conant m self-iosum for Wartime's Compen- r
sstion,m provided for by Section 37W of Ne Labor Code.for Ne performance of Ne - -
workforwhichNispermitisissucd.
0 1 have and will maintain Workcr's Compensation Insurance,as required by Section
3700 of NC labor Code,for Ne performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance earner and Policy number art: -
Cartier. Policy No.:
CERTIFICATE OF EKEMPFlON FROM WORKERS
COMPENSATION INSURANCE
(Thu section need not wcompleted if t W permit is Intend hundreddollars(SI10)
or less.) // �
I ccmfv that in me performance of Ne work for which this permit is'Gudo,1 shall nut -
c.•nployany'persoa in any manncrsty- b o su 'est to W ;csi ComPcrsation
Laws of California,Dae- ,-
Applicant ,
NOTICE TO APPLICANT:If,after making this CcniOcae of Exemption,you should •'
become subject to the Worker'a Compensation provisions of the Labor Code,you must
.J z forthwith comply with such provisions or this permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-i I hereby affirm genth
that there is a construction lending acy for e performance of
x Ne work for which this permit is issued(Sec.3197.Civ.C.)
GQ Ld dcrs Namc
=) z Lenders Address
U Q 1 certify that 1 have read this appliemion and sure that the above information is
D. P correct.1 agree to comply with all city and county oNinantts and me laws minting to
0U Wilding convection,and hereby aodurim mpmxnuows of this city to enter upon the
r W above-mentioned progeny for inspection purpeaes
(—'C (We)agree to sew,indemnify and keep harralm the City of Cupcoido against
p3 habdnties judgments costs and eapc.which may in any way.cane against said Ory
U z m eonxq of the grant g ts
^^ APPLICANT'UNDERSTA S AND WILL COMPLY WITH ALL NON POINT Issued by , Date2?�S
SOURCEREGUU,�TYION sero tee•°`.
�� ? 'a
Signature bf AppliranpConuaetor " f.. Date
HAZARDOUS MATERIALS DISCLOSURE "Type Of ROOf n
Will Ne applicant ar rut=Wilding occupant store or handle Wcani us material
as defined by the Cupertino Municipal Code.Chapmf 9.12,and Ne Hcalth and Safety
.
Seem.25532(.)? • All roofs shall be inspected prior to any roofing material being installed.DYea � '
Will the app mmu future building occupant use equipment rr devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit havartleus air contaminants az JcEmcd by the Bay Arca Air Quality Management all new materials for inspection.
Disuia? �
��
Dyes bre
1 have read rhe hvaMoms materials requirements under Chapter6.95 of the Califor-
nia Hcalth&Safmy Cock,Sccuom 25505,25533 and 25534.1 understand Muifthc Wilding
doesnot curren0y haw noon dna it is my responsibility to nntilj the occupant of the
myuircmcnn ten bemetpd isspaneeof.ednird,mrradppandr. Signature of Applicant Date
owner co authodrsd.,lot Dae All roof coverings to be Class ••B•'or better
• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34214025.00
DATE ISSUED. . . . . . . : 07/27/2005
RECEIPT #. . . . . : . . . : 30544
REFERENCE ID # . . . : 05070174
SITE ADDRESS . . . . . : 10110 LEBANON DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : SAN JOSE CA, 95129-3630
RECEIVED FROM . . . . : ANDREW KO
CONTRACTOR . . . . . . . : ANDREW KO LIC # 26141
COMPANY . . . . . . . . . . : ANDY'S CONSTRUCTION
ADDRESS . . . . . . . . . . : 10110 LEBANON DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 735-0111
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
___ __________ __________ __________
BTEMP FLAT RATE 1.00 62 .10 0.00 62.10 0.00
__________ __________ __________ ----------
TOTAL PERMIT 62.10 0.00 62.10 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -----______-----__
.CHECK 62.10 918
TOTAL RECEIPT 62.10
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
Community Development
10300 Torre Avenue
i;
;u Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
PEkTINO .
Building Department
JOB ADDRESS: PERMIT #
0 o ua n on VV, 0,C-O?017
OWNER'S NAME: &6j rew V4 O PHONE # D 9nZ— 5-6 Z
GENERAL CONTRACTOR: h Ccs Uc ,,oy7 FAX# 0 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
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
0
Owner/Contractor Signature bate
J�01017 �
CITY OF CUPERTINO
DEMO
CITY OF
O CUPEkTINO PERMIT APPLICATION FORM
APN # 3 q 2,- 14 _ 02 S- Date:
1� 0
Building Address: /
so 0 Le avon v_ Cit ev-t'v\v
Owner's Name- Phone #:
h�re- w K L ,8)2oa -41-
Contractor: Aod o(� License #: //l
OI'1 (.!L � O l g
Contact: � Phone #:
Applicant/Contract r: I
Building Permit fnfo:
Bldg Elect Plumb Mech
Job Description:
Residential: 211 C I Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
�-
• Type of Construction: Occupancy Group:
Qty. if
Applicable Fee TD Fee Description Fee Group
BPERMFEE Blda Permit Fees BUILIDNG
BSETSMICOM Seismic Commercial BUILONG
BSEISM ICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG