05120106 CITY OF CUPERTINO r'" ' rte$, -
BUILDING DIVISION PERMIT CONTRACTO) ORMATION,h
BUILDING ADDRESS: EILEEN% PENG PERMIT NO.0 5 12 0 10 6
R'S NAME: PERMIT ISSUE DATE
EILEEN PENG 12/19/2005
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3 o ij LICENSED CONTRACTOR'S DECLARATION
of hap
1 botchy affirm Net 1 am Incensed under Provision ns of Chapter ai(commencing lob Description
IN Section 7l1(IU)of DlWimn 3 m(thc Business ane Dafesaimu Code,aM my license Is
mmllmreeandeffect REPIPE DUPLEX WATER. PIPES
jn a License Class Lie.a
9 f Dau Contractor
ARCHITECTS DECLARATION
1 understand my plana shall he Dead n public records
U
=cad Licensed Professional
g OWNER-BUILDER DECLARATION
4 I I hereby affirm that I am exempt form the Commence,License Law for do
02 following meson.(Section 7(31.5,Business and Profession Code:My city m county
3 Pi which requires a Permit te mmWuct alter.Improve,demollah.or repair any structure $1000
poor was iuuence,also requires the applicant far such permit to fin asigned staxemem
ppE<
Met Mafocused pursuiminMeprovinces ofMeCcnumma'sU..Law(Chapter 9 Sq.Ft. Floor Area Valuation
Y (commencing with Section 7000)of Division S Mare Businesa and Profession Cade)or
Man heu exempt therefrom and the been for the alleged exemption.My violation of
Section 7051.5 by any applicant for a permit subjects the applicant to a civil penalty of kPilit
99WFer_V0 Occupancy Type
on,mart Nan Bw hundred dalWs($5005
❑1,as owner of ante property.or my employees with wages as their sale compenndon,
will do the work and themmunc is at Intended or offend forsale(Sec.7014,Business
and Profession Cade:The Contractors Lunge Law dams not apply in an owner of Required Inspections
property who builds orlmpraveathereon,and whodassuch work htmealforturough his +
awn employees,provided thatsuch improvements art not Intended orofferns for sale.If, i
however.the building or improvement Is sold within ane year of completion.the owner.
builder will ban the burden of paving Out M did rot build or Improve for purpose of
til/c,7.
m I.u owner of the property am exclusively coming with liamed contractors in
construct Ne project(See.7064,Business and Prefesslans Cade:)The Contrectar's Lt.
came Law does not apply in an owner of prapeny who Wilds or improve thereon,and.
who contracts forsuch pmkcu with a cormous q lianesed pursuant to Me Contraelera
License Law.
❑lam exemptander ec, .B&PC fm this rD/►�_��
r V
Data
?'
O KERS COh ENSATI NDECLARAIT
I hereby errs under Penalty of Peder arc of the following deadantians:
1 ban and will mainuin•Cenifiaumf Centel maelf-iuum fa WorkaMsCompen-
suion,u provided for by Section 5700 of the Labor Code,for Ne performanee of the
work for which this Permit is issued.
❑I boom and will maintain Workers Compensation huuruce.ss required by section
5700 of the Labor Cada,for the performance of the work for which this Permit is issued.
My Worker's Compensation Insuuna anis and Policy number art:
Center. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This eacMor card notbocompleted If the permit Is formic hundred dollars($100)
m sass)
I certify Net in Ne performance of the v a k for which Nis permit is signs.l shall not
employ any person in any manneran tit c sr j9ctto the Worken'Compenation
Laws of Califomia,Da
Applicant
NOTICE TO APPLICANT:IF.Mr mukthil this C tilcau of Exemption,you thoDW
become subject in Ne Worker's Compevution prow ions of the Labor Code,you mus,
.,O foMwithmmplywith Lich proWinns or Nis perm Mall W damns mvmkns.
z CONSTRUCTION LENDING AGENCY
(.r I bereby a Rum that then Its construction lendingagcmy ym the performance of
a> the work for which this permit Is issued(Sec.5097,Ci,C.)
W�Q LeMees Name ,
r7 z Iander's Md.
C)Q I certify,that 1 Mw read this application and sum that Me above Information is
ly F00=1.I agree m comply with all city and county ordinances and sum laws relating to
QC.) building construction,and hereby sunbathe opmesenualm ofthis city in enter upon Me
W .Imve-mentianns property for Impaction purposes.
fY (We)agree In an.indemnify and kap harmless the City of Cupertino against
w.t rag liabilities,ludgmcnLL costs and expen•-st which may in any my we=against mid City
f,7 in consequence of Me Smoting of this Permit I ,S
r1- APPLICANT UNDERSTANDS AND WILL COMPLY WITH All.NON-POINT Issued by: Date ` —0
SOURCE REGU TIONS. (24 I I &s-
Re-roofs
Si{nuurc of App can o vector Da
HAZARDOUS MATERI LS DISCLOSURE Type of Roof
Wllltheappllantorfuture Wilding pmtstomarbanduhvmdoumauoal
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Ely"
'�No
All roofs shall be inspected prior to any roofing material being installed.
Y
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hvardnus air contaminants u dcfined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ya POND
1 have mad the hvudom materials requirements under Chapter 6.95 of the Califs-
meHealth&Safety Coda,Section,25505,15577 and 25554.I understand dist if Mu Wilding
does ml currently hero a unapt,that h u my responsibility m noufy Mu occupant n(dte
requirements which mug eprior in us.arte f.ccmlmateafa panty. SignatureofApplicant Date
tu lxl! of
Owner or authorized agent Data All roof coverings to be Class"B"Or better
Community Development
0 Torre Avenue
Cupertino C 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�PEf�TINO
Build.ing Department
JOB ADDRESS: PERMIT #
83 I ,&,_. 05-1.p,0 0
OWNER'S NAME: PHONE #.lot05—
GENERAL CONTRACTOR � FAX #
Tie-*409- 31 q--28�
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
P _ - 23-06
Owner/CContra r Signature Date
Community Development
10300 Torre Avenue
G '. J Cupertino CA 95014
Telephone(408)777-3228
fCITY OF Fax(408)777-3333
jPEkj1N0
Building De artment
JOB ADDRESS: PERMIT#
3 i
OWNER'S AME: PHONE #
GENERAL CONTRACTOR: T, a. FAX#
I am not using any subcontractors: T a.11. 05;-
Signature
SSignature 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/ ontra for Signature Date
~ CITY OF CUPERTINO
Ou RREPIPE/SEWERS/MAIN SERVICECOF
UPEITY RTINO PERMIT APPLICATION FORM
APN # 3 6c, 4 0� Date:
Building Address:(
W
Owner's Name: Phone#:
Ede-cwt/ 40do—Z — O
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
0t- — 0!5-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential X omm rcial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas PiIjing System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING.
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
J7