05060163 CITY OF CUPERTINO
BUILDING DIVISION PEI ,�'C-oNTTRA`C'fdk'1'&F
BUILDING ADDRESS: TUNG KET GHAT PtuRmITNO05060163
10735 PENINSULAR AV
OWNER'S NAME: PERMIT ISSUE DATA
TUNG KET GRAI 08/24/200S
ONE: SANITARY NO. CONTROL NO.
ARCHOECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLO
MECH
�Oij LICENSED CONTIIACTOWS DECLARATION
Ibc I hamloy affirm that I sm licarsom under provisions Of Chapter 9(contrasting Job Description
10 Section 70110)of DNIalcut 3.1'thas Bud.and Pnifiesumas Code,and my[Imen¢it
in full force and offect.
REPLACE CENRE GAS FURNACE
D Ll License Class-Lk.0 hZ;: Data Contractor
_ARCHnEGMS DECLARATION
I undersand my plans shall he ussad as public excoms; L 11 Z/
Is
Zt Licensed Prormtomal OWNER.BUILDER DECLARATION
iEx I hereby alffirm dust I am exempt firmin the contrastor's License Low for the
E a following mason.(Section 703 Business ad Profession Code:Any city or county
which imPtims a permit to construct.altar.Wpmw,demolish.or repair my structure M. it 2 0 0
Prior it)us issuance,also rcquims the applicant for such Permit to file a signed statement
that M is licensed PU=anL W do,provisions of we Contractor's Liesmse Law(Chapter 9 Sq.Ft.Floor Area Valuation
ad (commencing with Section TODD)Of Division 3 of the Business and Professions Code)or
'hat he is ewmpt therefrom and the hasuct for the alleged cwmpdon.Any violation of
Section 7031.5 by any applicant for a permit objects do applicant in.civil Penalty of .3 eroo Occuparf6y T�pse
.I am than five hundred ikillm,(M).
0 1,as Owner offt property,or my employees with wages a their sole compensation,
willdothework.andthestructumismililnMn&dwo(fcmdforsate(Sm.7044,Busi&u
Nd Ponfousim"Code:Th.Commutes Lictme,Law doom Out apply to an owner of Required Inspections
Property who builds or improves themon,and who does such work himself or through his
Own employces,provided that such Improvements are not intended oroffered for nit.If.
however,the Wilding or improvement Is sold within one year of completion,the meet.
builder will haw the human of proving that W did Out Wild or Improve for purpose of
cal..).
0 1.as Owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Profession Code:)The Customers Li.
came Law it=not apply to an Owner of property who Wilds or Immows thereon,so .
who contracts for such projects with a contrantor(s)licensed pursuant in this Committees
Lt...Law.
0 lmse.emplimdg,See. _,B&PCfnLh1secaoa
Owner Date-
WORKERI COMPENSATION DECLARATION
I humby same under penalty of perjury,one of the following deciaredloare
I haw and will maintain a Certificate of Consent to self-lasum for Worken's ComKn
sadon,as provided far by Section 37M of the Labor Core,for the performance of ths,
anxic for which this parmit is issued.
0 1 have and will mainum Worker's Compensation as required by Section
137M of the Labor Code.for ft Performance of the work for which this permit is Lsousecl.
My Worker's Compereastion, artier and Policy number arc:
Carrier.-Policy No.:
CERTIFICATE OF IDIEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Dica searmin need mulliccorapictod iftbe permit Is forium hundred&It=(SIN)
or was.)
I tinily the,in the parimminamv of We it forw a perm1.is issued.I shall nm..pl'ar'Knumitian manners. oulle
Laws Of California.Dau
Applicant we
NOTICE TO APPLICANT.If.after making this Ccinficaus olExemption.You Fould
become subject In the Worker's Compensation provisions of the Learn Cadc,you must
z forshwim comply with such provisions or this permit shall to&cmW revoked.
CONSTRUCTION LENDING AGENCY
H4 I hereby Afflinn that them it a construction lending agency for that Performance of
r; the.,it for which this Permit 4 issued(See 3097,Civ.C.)
Lod.es Name
Lenders Address
I cenify that I haw read this application and sum that the show information is
U, correct.I agree to comply with all city and county ordinances and state laws totaling 10
building construction,and hereby authorize representatives of Nis city to enter upon the
above-mentioned property for Inspection purpose,.
Lit (We)agree to saw,indemnify and keep hationless the City of Cupertino ail
ver rA liabilities judgments.cast and expenses which may in any way accout against said City
in consequence of the granting Of this pornall.
APPLICANT UNDERSTANDS AND I by: Date
, W CO?(?W1711 A - NT Issued
SOURCE REGULATI, I
Sig... J'ApplicautConcessewir IF 110C Re-roofs
HAZARDOUS MATERIALS DISCLOSURE . flat Type of Roof
MR the applicant or low.Wilding Occupant arm or hard'.Wessel..inviedid
as definad by the Cupertino Municipal Code.Chapter 9.12, it the Health and Safety
Imle,Section 25532(.)? C7-�
ow, &(NO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment at dievices,which If a roof is installed without first obtaining an inspection,I agree to remove
mil WyAndout,air coo omin a dclincil by the Bay Aem Air Quality MiselararmL all new materials for inspection.
Mabel?
El yies, 7N.
I hawicad the hatrudoeseuntri.1s raquirmasums underChaptar 6,95ofthe Califor.
nis Health&SaficiyCodc.Socacm25505.25533 and 25534.1 undormerst thisifibe building
does.1 Ctmofflly he. thati
mcquorenic Signature of Applicant Date
Ovmcr.,autha ca. en ,m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
aCOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEf�TINO
Building Department
JOB ADDRESS: PERMIT
l c l?�5 �►J 1 ust,��
OWNER'S NAME: I PHONE # 6— zJT- 8'61
GENERAL CONTRACTOR FAX#
I am not using any subcontractors:
gtfgnaturve 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
caner/C htract Signature Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child)will perform
A. — 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 perfo,rmed
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.
Persor/Firm Address/City . Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
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: 6 ° ;
Job Address: ' Permit# QrO 61*D /63
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
aCITYF 103DO Torre
Phon (408)7773226
CUPEkTINO
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 Building 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 permit 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 compensation
contributions.
There 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 U.S.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
Printed on Recycled Paper
G�� CITY OF CUPERTINO
FURNACE/ACS
CUPERTINO PERMIT APPLICATION FORM
APN# „ , , p� t Date: / s J�
Building Address: I t� r
Owner's Name: 11 Phone#:
Contractor: , License#:
Contact: J l,& �s! I Cupertino Business License#:
Building Permit Info: �7
Bldg ❑ Elect Plumb ❑ Mech l9
Job Description: r_ Ce-ht—o— Pw-nc,(:j*- C F-oraJ A e/\ a5k F.,(-L4
Residential . W` Commercial ❑ I
For Residential Inst llations:
Attic ❑ I” floor M 2"a floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
$ao
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING