03080002 (4) CITY OFCUPLIC11NO
BLILDRJG nlwSION PERMIT l• ,�F�' I-2ACTOR INFORMAT=10.
BUILDING ADDRESS: PERMIT NLb 3 080002
10114 CONGRRcq PT,
OWNER'S NAME: PERMIT ISSUE DATE
YAO—CHENG SONG 08/04/2003
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELF,Cr PLUMB MECIi
0 0 0 0
00 LICENSED CONTRACTOR'S DECLARATION
p 1 hereby affirm that 1 am licensed under provisions of chapter v(commencing Job Description
jW with Section TOOK)of Division 3 of the Business and Professions Code,and my license is
tb infall fomeand effect. REVISION--IN HOUSE USE ONLY
�2 closes Lip
n Date—Contractor
eNO NEW PERMIT ISSUED/ORIG. #03070098
ARCHITECTS DECLARATION
a< I understand my plans shall he used as public records ADD 1 MORE SKYLIGHT
n.0
ON Licensed Professional
g OWNER-BUILDER DECLARATION
a Y 1 hereby alarm that I am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and professions Code:Any city nr county
m which requires a permit lit construct.alter,improve,demolish,or repair any structure
t¢y
Poor I() issuance,also requires the applicant forsuch permiuo rile a signedsmmment
:ro that he ishee sudpursuantintheprovisionsardmeontactorsLiucaseLaw(Chaplet9 Sq. Ft. Floor Area Valuation
�f- (commencing with Section 7000)ofDivision 3 oftht Busmessand Professions Coaled or $2000
�
! $ Nal he is exempt Remfmm and the Buis for the alleged exemption.Any violation of $2 0 0 0
Section 7031.5 by any applicant for a permit subjects fire applicant to a civil Penally of APN Number
nut more than five handled dollars($300). Occupancy Type
❑1,as owner Or the pfoperty,of my cmployces with wages as their sole compensation, 32653 046 . 00
will do the work,and the structure is not intended or offered for sale(Sec.71014,Busincex
and Pfofcssi(m Codc:The Contractors License Law does not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are nut intended or offered for sale.If, 101 — FOUNDATION
however,the building or improvement is said within one year of completion.the owner-
builder will have me wfden of proving Thal he did nut wild oe far purp
r improve ose of. 10 2 — PIERS
art`')' 103 — UFER
❑ 1,as owner of the property,am exclusively contacting with licensed eonoactom to 104 — REBAR
consumer the project(Sec.70,14.Business and Professions Code:)The Contractors Ll-
ee a Law does or apply to an owner or property who wads art improves themon,and 105 — ANCHOR BOLTS
who contracts for such projects with a contactor(:)licensed purauant to the Contactors nse Law.
Lic106 — SEWER & WATER
e
❑ l am exempt under See. ,B&P C for this reason 202 — UNDERFLOOR PLUMBING
Owner Date 203 — UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION
EON
hereby aramn under Penalty of perjury are of the following declarations: 204 — UNDERFLOOR FRAME
veandwillmainainaCertirermofConsenttoselr-insumforWorker'sCompen- 205 — UNDERFLOOR INSULATION
ax provided for by Section 3700 or the Labor Code,for the periormoug,of the 3 01 — ROUGH PLUMBING
work for which this permit is Issued. 302 — TUB & OR SHOWER
❑1 ban and will maintain Worker's Compensation Insuance,as required by Stenion
37W of life Labor Code,for fire Performance of are work for which this Permit is goord. 303 — ROUGH MECHANICAL
My Worker's Compensation Insurance carrier and Policy number am: 304 — ROUGH ELECTRICAL
Carrico —Pit icy No.: 3 05 — FRAME
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE 306 — HOLDOWNS
or (This scaion need not he completed if the lcrmis is fm ante hundred dollars($I Big 307 — INSULATION
IsentrJ 308 — SHEETROCK
employ certify that er the n any manec or IM work for which this permit is isuedm shall nm
Lawso any Person in any manncrmumbecome subject to the Warkcri Compensation 309 — EXTERIOR LATH
LawsofCalifornia.°d1c 310 — INTERIOR LATH
Applicant
NOTICE TO APPLICANT:If,Offer making this Celli ficate of Exemption,you should 311 — SCRATCH COAT
become subject to the Worker's Compensation previsions of the Lahor Code,you most
Z forthwith comply with such provisions of this Permit shall w deemed revoked. 3 13 — ROOF NAIL
10
CONSTRUCTION LENDING AGENCY 501 — FINAL ELECTRICAL ENERGY
. ? Iforhereby which
Oat them isatontSee.30 lending agency for the perfurmancc of 502 — FINAL PLUMBING ENERGY
due work for which Ihrs permit is issued(Sec.J097,Civ.C.7
)q trnaeaName 503 — FINAL MECHANICAL ENERGY
3 Lend`fsAddfess 504 — FINAL BUILDING ENERGY
p 1 certify Nat I have read this application and state that are above information is 505 — FINAL ELECTRICAL
(—' correct.1 agree to cumply with all city and county ordinances and state laws relating to
jUshme-geonsuuclim and hereby mnthonprenses. mivcs of this city mcmer sport me GAS TEST
shove-mconstrucfifirmt!property for inspection tuition,repress
a. (We)agree to save,indemnify and keep harmless the City orCupertino against 0 7 FIN
rn liabilities.judgments.costsand upenuxwhich may inanyway seems against aiacny 5 A C ICJ
)',Z in conscquencc of the graining of this peroral.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOURCEREGULATIONS.
Signature of Applicanoeonfacer Date Re-roofs 514 INAL PUBLIC WORKS r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle ha'sarduus material
u defined by the Cuptenino Municipal,Code.Chapter 9.12,and the Health and Safety
Code.section 25532(a)+
❑Ycx (3 No All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building occu ant use equipment If a roof is.installed without first obtainingan inspection, I agree to remove
nn s P q it Qu or devices which P g
azarduus air contaminants u defined by the Bay Arca Air Quality Management all new materials for In$pCChOn.
ort?
❑Ycs L]No
1 have mad the haardnus materials requirements under Chapwr6.95 of the Califon
mal-calth is Safmy Code.Student 25N)5.25533 and 25534.1 undcmund that if the tuilding
docs not currently haw a tefront,that it u my responsibility to unity the Occupant of the
requirements which mug be met poor to issuance arta Ccoadmare of Occupancy, Signature of Applicant Date
Owner or authorised agent Date All roof coverings to be Class "B" or better
OWIW-BUILDER VERIFICATIO*
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
41 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, % J Date: =(,IX
765
Job Address: / �/ /� (°t/J2� 0111 (l� CP lt�I?�?� Cjpp/�Pemtit# 05Q-70
�
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
•
City of Cupertino Building Department
t I CITY OF 10300 Torre Avenin
C V P E Q I N O Phone: (408)777-322
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 urotect vourself 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 compensatioro
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 maybe 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
•
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CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 32653046 . 00
DATE ISSUED. . . . . . . : 08/01/2003
RECEIPT # • . . . . . . . . : 22685
REFERENCE ID # . . . : 03080002
SITE ADDRESS . . . . . : 10114 CONGRESS PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER YAO-CHENG SONG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5721
RECEIVED FROM . . . . : SONG YAO CHENG
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
WE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - ------- - - ------- - ---------- -- - - -- - ------- - -
13PLANCKREP HOURS 1 . 00 55 . 50 0 . 00 55 . 50 0 . 00
----- ----- - --------- -- ------- - ------- - --
TOTAL PERMIT 55 . 50 0 . 00 55 . 50 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- - --------- -- ---------- -
OTHER 55 . 50 VISA
TOTAL RECEIPT 55 . 50
C*Y OF CUPERTINO o O
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
AIL
141kPN # 2 / ,c.1 -6 9 o/ Date: O
Building Address:: > l Mailing Address (if different from building address):
( D 1¢ L CF 9-to/<i
Owner's Name: Phone#' / _Z
CQ - b
Contractor: License#:
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: u ancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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
BBOILER5 _ 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
� 2z6 �S
1 of
CCS`- CW OF CUPERTINO
CITY Of PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping stem Fee PLUMBING
S
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 rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace > I 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
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aCitiffl
CITY OF CUPERTIN%
CUP TYOF O PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, 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 Inspection BUILDING
BSW1M 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 Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
I
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