05080058 CITY OF CUPERTINO
BUILDING DIVISION PERMIT -INFTCONRACTOR ORMATION ; .
BUILDING ADDRESS: PERMIT NO.0 5 0 8 0 0 5 8
1068 NOVEMBER DR
NER'S NAME: PERMIT ISSUE DATE
OW
SUNSOO PARK 08/08/2005
NE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Op LICENSED CONTRACTOR'S DECLARATION
u hereJbDescri Description
O 0 O
C I by affio
rm that 1 am licensed under provisions of Chapter 9(commencing p V N n
Uro with Section 70(10)of Division 3 of the Busi.and Professions Code,and my Jim.is E[lJ Y�J
nee infall fonx .i.andcffa �,�, EXTENSION ELECT. RECEPTICAL
y,= License sem- Lk.M r'J
X1 Dam C'Smaxism
DECL ONTRACTOR: LAND MOSAICS INC /,, �
££u` ARCHITECT'S DECLARATION
4 C I undersand my plans shall W used u public reeoNs (r}-r
J kz
�C',,QLicensed PndcssionalOWNERBUILDER DECLARATION
A 1 hereby affirm that 1 am exempt form the Contractors License Law for the
i 00 following mason.(Section 713 1.5,Business and Prefoaimas Cote:Any city or county
e$ which requires A permit ro construct.alar,imprison,dcmmlixb,or repair any sw,tum fJEi' /f
°Zy prism iuissuance.also mquiresthc applicant(orsuch petmitto file a signed statement
E O that he is licensed pursuant in the provisionofthe Cont=tor'sLiccnscLaw(Chapter 9 Sq.Ft. Floor Area Valaatiotii t00
(commencing with Section 7000)of Division 3 of the Business and Profession Code)or
that he is exempt slcmfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fa A Permit.subjeeu the applicant m•ciAl penalty of APN Number Occas
amt mere than fiw<hundred dollars(SSW), 36216034 . 00
Pansy Type
C1I,uowwrotl pmpcny,ormyemployc"withwag"utheirmlte Nnadm.
willdotWwork,andthemuaumunotinmM doroffe fwa (Sa.7014,Buinus
and Professions Code:no Contractor's License law dors not apply in an owner of Required Inspections
property who bui lds or i m proves Nemo n,and who dines suc h weak himself or through his
own employees,provided that such impmaemwu arc not intended or offered for We.IL
however,the building or improvement is sold within on year of completion,the owner
builder wig have Use burden of proving that he did not build or improve for purpose of
ale.).
I,as owner of the propeny am exclusively contracting with licensed cmn>timrs m
construct the project(Sec.7014,Business and Professions Crede:)The Convector's U.
cone Law dors not apply tin an owner of property who Wilds or improve thereon,and
Who contracts for soh projects with a contrsmr(s)Iiceoed puraam m the Contractor's
License law.
t]I ism exempt under Scc. ,B&P C for Nis resume
Own" Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury nee of the following doclarauona:
I have and will maintain a Cenifiom of Conserv in self-moue four WorkcesCanpm-
7c"
rim.u provided for by Section 3700 of the labor Code,for the performance of the
W
for which Nis permit is issued.
1 haat and will maintain Weaken Compensation Insurance.u required by Section
00 of the Labor Code,for the performance of the work for which this permit is issued.
y Workere's C�ompeFlu don nsurance carrier and Policy number arertier. l]a(Mla�I1�T, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Critissection wed not W canple ed if the,Permit is foronehunded dollars($100)
or loss.)
1 certify that in the perfomnmeo of the work for which this Permit is isswd,I.Nall not
employ any Perron in my mamierm at in become subject to the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this CeniOe.m of Exemption,you should
become subject in the Worker's Compcnauon provisions of the Labor Code,you most
.J O forthwith comply with such prnvimmns ser this Permit shall he deemed rcwkcd.
'Z^'y CONSTRUCTION LENDING AGENCY
(~ I hereby AITum Nam Vert is A wnstrectinn lending agency for Ne lcrfornanscof
(Yi the work for which this wonit is issued(Sec.3097.Civ.C.)
Lender's Name
z Innder's Address ,
U Q 1 cart that 1 have read Ws application and Aute that this aW see infomglion is
17. P cortect.l Agra to comply with all city and county ordinates and sun laws relating to
0 building mnsitction,and hereby authorise reprcmnestivca of this city to enter upon the
�W aWve-mentioned pmperty for iopecumn purposes
t„r G. (We)agree to arc,indemnify and kap harmless the City of Cupertino against
U liabilities,judgments,ensu a
And exnaes which may in my wry accts against a id City
Z
I'consegwnee of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOU RCf„R CATIONS. y Date
{ ale Re-roofs `L
Sign...o IicanVC cmr pate
H=AUS MATERIALS DISCLOSURE Type of Roof
Will applicant in future Wilding occup.ntsmm or handle hexa emus material
AA dofiwd by the Cupenim Municipal Code,Chapmr 9.12,and the Halth And Safety
Cak.Section 25532(.)?
pYen
)<No All roofs shall be inspected prior to any roofing material being installed.
Will thea Applicant or future building wc.ant use If a roof is installed without first obtaining an inspection,I agree to remove
pp g p Area
Air Quality sena a which g
h havardnus air cwuminanu u dc0ncd by Nc Bay Arca Air Quality Management all new materials for inspection.
DiaVict? ``''
❑Yes /VNo
1 have mad the hvardmus materials osgibrmenu under Chapter 6.95 of du,Califm-
nuHCHth&Safely Code,Sectint 25505.25533 And 25534.1 undcrsund them if the Wilding
docswt cu l here a mnane Net ice u my responsibility m nuufy the meopmt of the
rtyuiremc is w h nuc W met pdorm issuawa of a Certificate of .pan
A
Signature of Applicant Date
Owner ren. h . .sent p,S a All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMTr #
< /vo V61q C—/? le , r-)K—D 9-00�J-
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: 4,o7 FAX #
.I am not using any subcontractors:
Si a Date
Please check applicable subcontractors and om lete the followinginformation:
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
IN APN # 2/Zoe Date: I /h /05-
Building
5-
Building Add ess: Mailing Address (if different from building address):
10d6 /UOVe r
Owner's Name, AW Phone #: «)
M - 7/a
Contractor: License #:
IGS 7.;c. ,S� �
Contact: Phone:C 191-3 upertino Business License#:
NO, Fax:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Descript'on:
Residential C—,&&✓%wJ ,rel Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: 300 Occupancy Group:4amep (0
Type of Construction: Please check this box if the project is a
second-sto addition: ❑
ro"ect Size: Standard Laze ❑ Major ❑
uantit Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS 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 Elee Svcs 600V<= 200A ELECTRICAL
BENERGY Ener y BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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F
?, CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEI,TINO
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Conon Plumb PLUMBING
BOVERTIPAE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor 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
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI A liance Install MECHANICAL
BREMBUSWAY Remodel Buswa s ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT R air/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUP TYOF O PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmd] 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
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
- — -- PPERMITFEE—_. —Plumbin PermifIssue PLUMBING
- — —
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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