05110139 CITY OFCUPERTINO y*' s*+ke rd' ��•"'"• �`�'""" 4
BUILDING DIVISION PERMIT t0NT"CTI INFURMATI
BUILDING ADDRESS: J=AQIAN WAN PERMITND.OS11O139
- OWNER'S NAME: PERMIT ISSUE DATE
JIA IAN WAN
NE: SANITARY NO. CONTROL NO.
ARCH=/ENGINEER: BUILDING PERMIT INFO
BLDrO ELECTO PLUMB MECH
Sop LICENSED COKIRACfOR3 DECLARATION lob Description
I 1 hemby Arm that 1 am licensed unlet provisions of Chapter 9(ammeaing
with Sada.700M mDWiAon 3 ofdee B.A.and Profession,Cade.and my license is
in full force and Arm REPLACE TUB TO WHIRPOOL
jn¢ 4mmm Clue Us.0
3 Dem Contractor
ARCHITECT'S DECLARATION
f I understand my Flee shall be used a public raters
yu. Licensed ProfatianJ �.
U.
y Oat I am exempt
from
m me RATION
Commem F[��
2 i S 1 kmhy.(Rete on 1 em caempt from Po Canons Cot Lkenm law for cite C,
p o following requires
a.(Salon 703 1.5,Business and vis.d atom Code:Any city a county //^' n p?/
3$ which its isu a Permit re enrtewc4 atw.Wprove,dpermit t,or c.sig ed uroctun (.�'i`l w rJ O O
y Prior m its iun,nca,amen require ma applicant forsudthe Cors Permit o Ne so Law statement s y
08 that hoeWenscthSectmmtheProvisions 3ofdre usines'Wan,afaonsGodw9 Sq.Ft.Floor Area t'c anon
5 �
(commenting pth 70DO)of and
Dl*for oathsegelnexe end on.My viCode)or
S�— thad ha e aumPr rknfrom and Ne bee far the atmie0 exemption.My Moedon of
Smeller,7031.5 by any applicant for a permit subjects the applicant In•civil Penalty of
Out mom than five hundmY dollen(5508} r �'�c f% .Type
0 1,u own,of the popeny,w my mploym MN wase u tk4 mit campemdon. `
will do tha work•and the Ammon is not mounted ar offend fusam(Sm.7044,Bud.
and Poresdons Cade:The Contracmrs License Law dm ant apply an an ounces of _ Required Inspections
Property who Wndaarimprowe derann.mil whoduessuch wok hmtaelfor though his
awn emPloym,povlend that such Improvements are not intended oraffemd rorak If,
however,rite building sur Improvemem is sold wasmose year of compimon•the owner.
builder will have the burden of proving that k did nor Wild or Improve for Fortune of
sale.).
0 1.as Owner of the property.w exclusively contracting with BaneW contractor to
construct the pmjm(Sec.70W,Business and Profudan,Code:)The Communes U.
mice taw does not appy an an owner a preprry"k Wilds or impows thereon.and.
who contruv for such projects with aanntmm(s)licensed Forums m the Conocars
Lismtme taw.
0 1 m exempt undo Set B h P C for the moon
1031.00
ner i'�' Dam ll
//YOy •NSA ON DECLARATION
.1 w4y aw.under penalty a(perjury tete of the following dedmadonr.
I have and will..Irwin a Certificate of Consent m elf-insure for Worker'sCompan-
on,uprovided for by Sation 3700 of the Labor Code,for dee peAarmana of dee
rs for which this permit is issued.
1 have and will maintain Workers Cempen,arian Inamnce,u required by Section
0(the labor Code,far the perform.of the work for which the pemdt 4 Warkera Compeneadoe 4uuruta artier and Poliry numbv are:
rtier. Polley Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Otis tmlan need sot ho eomplemd If the permit Is formte hundeaddanm($109)
or lest)
I certify dust in me performance of the work fer which this permit 4 Luued.I shall ant
cmpmoy any Pcrsen in any m ces"n u m Myoma mbeu m me Workers'Cnetpeaud7
Laws of Caliromma D; /� j'//L9:;Zf '
App ant
NOTICE TO :IfAQr making the Certificate of Feeion•you should
dsome subject an the workers compemdon poveians of cite V r Cade,you mous
.,O forthwith comply with such provisions or the Monti"bu domed invoked.
z CONSTRUCTION LENDING AGENCY
[-. Thereby atDrmhod them is a construction lending agency for the performance of
rl 7 the work for which the permit Is issued(Sec.3097.Civ.C.)
0 Lenders Nanm
7 Z lenders Addmsa
U O i cenify Nat I haw real this application and sum that the show Information is
(I+^ comtt 1 agree to comply with W city and county eminences and sou en mmaung to
building con,wetiom,and hereby Author=representatives or the city to creta upon the
t37 above-mi maned Property for inspection purposes.
(Wer)agree to save.indemnify and kap barm4sa the City of Cupertino against
fA limilWe•Judgmcnu,cow and expenses which may In any waysccme agaiutssid City (�
to consequence of the standing of the Date
POMIL Issued by: /� -d—ve—
APPLICANT U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOUR ONS.
f/ Re-roofs
ort sur HAZARDOUS MATERIALS DISCLOSURE Om Type of Roof
Will de applicant Or future Wilding u supsea Yore"I m R:hmodae mmund
as defined by the Copeman Municipal Code.Chapter 9.13.and the Health and Safety
oda.Berman 25532(a)7
Oyes Otho All roofs shall be inspected prior to any roofing material being installed.
Will the appliewt or futum Wilding occupant use equipment Or device which If a roof is installed without first obtaining an inspection,I agree to remove
mit husorms air comminanu u defined by the Bay Ams Air Quilty Manapcmcnt all new materials for inspection.
1D,Armt7
0Yu ONo
I haw mad de ha=Nau materae requirenrsu underChIPM493ofole Califor-
aHeawBSafetycade.Seedon,25505.3!533 and75534.I mtdentsnd thatifthe building
es rot curremly haw a mnanL dent It a my respomadlity m nouu5ry0tchecyapc�cuYpam of cite
quimmcnu which roto k out Poor se issuance of a Comfi�m, iD / Signature of Applicant Date
artrnT"gm , ��2t 1/ /D�m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
.Za j, - Oa. at--6, (t O-rIl0 /3 9
OWNER'S NAME: i w WAV PHONE #( ) >4�Q
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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
I
e Contractor Signature Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
• A. N 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 performed
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 Insurance 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
_performed
.....................................................................................................................................................................................
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:
Job Address: ad 6 a Permit#
Any changes to the information provided on this form shall be submitted to the City of Cuvertino Build
Department.
City of Cupertino Building Department
CI 10300Torre Avenu
CUPERTINO ,on� f177�-3
Dear Property Owner:
An application for a building 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 possible liability if that person applies for the proper perrnit in his or her name.
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 to 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$200 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 compensatiov
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
espeaally 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 returned.
Very truly yours,
Building Department, •
City of Cupertino
Prirad on Recyded Paper
CITY OF CUPERTINO -
CUPEfZaa PERMIT APPLICATION FORM 0TV 0 �
N # 3 � Date:
Building Address: Mailing Address (if different from building address):
aa6�
Owner's Name: Phone#:
Contractor: License#:
81 VAAa �
Contact: ,, Phone: Cupertino Business License#:
fLWnA� Fax:
Building Permit Info: l e p19 a 6Aa" eex
Bldg [Z Elect ®' Plumb ❑ Mech ❑
Job Description:
Residential BF Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Proiect: Occupancy Group:
_7
Type of Construction: Please check this box if the project is a
l/&-/ second-story addition: ❑
ro'ect Size: Standard ❑ Large ❑ Maj or ❑
uant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
13BOILER2 Boiler> I OOK to 500K Btu MECHANICAL
B13OILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOMER5 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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CITY OF CUPERTINO
CUPEfZTINO PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
IRV BMTTIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM, New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERMAE 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 Interce for 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
BPSE«'AGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo . PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pipe PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRIiAN A/C Units <= 10,000 cfrn MECHANICAL
BREMAPPLI Appliance Install NfECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT LiLting Fixtures ELECTRICAL
BREINU7URN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREM=AT Heater Installation MECHANICAL
BREAMMOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPONVER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating h=ANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEY; 0,- PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSV M Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTED11PPERA1 Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERNII'TFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot I`/MCHANICAL
MPERAUTFEE Mech Permit Issuance MECHANICAL
PPERnHTFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUU-DING
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