07080202 CITY OF CUPERTINO +QMTIQN
BUILDING DIVISION PERMIT cm�r LGTo�I.
PERMIT NO.
BUiLI1 i��Df(ESPRING CT TBD - TO BE DETERMINED 07080202
j l PERMIT ISSUE DATE
OWNER'S NAME:
TIFFANY LIU 08/22/2007
SANITARY NO, CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
C4 Z LICENSED CONTRACTOR'S DECLARATION lob Description
oP I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is MAIN S E[VER LINE REPLACEMENT
=y in full force and IT r `r�
? License Class Lic.#
E p Date ti Contractor r f CO 0y 'e f
ARCHITECTS DECLARATION
i a a 1 understand my plans shall be used as public records
iyU
a y Licensed Professional
m OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractors License Law for the
:p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to file a signed statement Sq.Ft.Floor Area
that he is licensed pursuant to the provisions Valuation
?< of the Contractor's License Law(Chapter 9 $7 0 0 0
is (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number
not more than five hundred dollars($500). 37525037
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's u-
cense Law does not apply to an owner of property who builds or improves thereon.and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License law.
C]I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
LJ I have and will maintain a Certificate of Conscnt to self-insum for Workces Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: /
Cartier: L/b14-!1i LrLj'. Policy No.:W C 7L '; /s o
CERTIF7 TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z.- CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance.of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
z fenders Address
U 0 I certify that 1 have read this application and state that the above information is
LL. H correct.1 agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorise representatives of this city to enter upon the
a ahovc-mentioned property for inspection purposes.
(We.)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Ogre
�+ APPLICANT UN RSTANDS AND WIL LY WITH ALL NON-POINT Issued b;i: -
SOURCE R U TIONS.
• ,, -Zt- o Re-roof:
Signature of Applican Conuac or Dare Type of lZoof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hayardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
[3 Yes �o If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes CJ'No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a cnant,that it is my res i icy to noufy the occupant of the Date
reyuircmcntawhich tbemetpriorto'ss ertificatcmrOccupanry. Signature of Applicant
-,71_. All roof coverings to be Class"B" or better
Owner or authorized agent Date- --
Community Development
osj�
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
C17Y OF Fax(408)777-3333
`;UPEkTINO
Buildi n De artment
JOB ADDRESS: PERMIT #
OWNER'S N PHONE
-GENERAL CONTRACTOR: r o d FAX#
I am not using any subcontractors: - 9 Z
Si gnature 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
Owner/Contractor Signature Date
CITY OF CUPERTINO
12 ITEMS OF 2 PERMIT RECEIPT OPERATOR: CathyS
COPY # 1
Sec: Twp: Rng: Sub: B1}:: Lot:
APN 37525037 . 00
DATE ISSUED. . . . . . . : 08,'22/2007
RECEIPT #. . . . . . . . . . BS000002449
REFERENCE ID # . . . : 07080202
SITE ADDRESS 18651 PRING CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER TI'.�FANY LIU
ADDRESS 181-351 PING CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM RESCUE ROOTER
CONTRACTOR TB:D - TO BE DETERMINED LIC # 00096
COMPANY TB-.D - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- --- ------ ---------- ---------- ---------- ----
BPSEWER SEWER SYSTEM 1. 00 21 .58 0. 00 21.58 0. 00
PPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40.79 0.00
TOTAL PERMIT 62 .37 0. 00 62 .37 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 62 .37 0004327
---------------
TOTAL RECEIPT 62 .37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF C_.UPERTINO
REPIPE/ E W 1__;S/MAIN SERVICE
CIN Of
CUPEkTiNO PERMIT APPLICATION FORM
APN# S � � � 4 U � Date:
Building Address:
Owner's Name: Phone#:
Contractor: Phone: (- AM- Q 0 4-0 1 License#:
Resetle �vofer / GS1S
Contact: Phone: Cupertino Business License#:
01�e,
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential p Commercial ❑
Cost of Project: v
7Au
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Pipin System Fee PLUMBING
PPERMITFEE F lambing Permit Issuance PLUMBING
BPREPIPE F_e i e of Fixtures PLUMBING
BPFIXTURE Fblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER c ewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING