05090101 (2) CITY OF CUP ERTINOaapa,s.
BUILDING DIVISION PERMIT 3�CONTRACTTOR INFORMATION:
BUILDING ADDRESS: CHEROKEE CONTRACTING CO. PERMITNo05090101
.1146 DERBYSHIRE DR
OWNER'S NAME: PERMIT ISSUE DATE
RUPINGLIN LIN 356 MATHEW STEET 09/15/2005
INE:
SANITARY NO. CONTROL NO.
(408) 727-9850
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
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LICENSED CONIRACTOR'SDECLARATION Job Description
inu 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7")of Division 3 of the Businessand Professions Code,and my license is
. mnmrt ¢ode ea rj�C ZZ b INSTALL 4" LATERAL C/O
j�= Liccnsc 0. Ue
nFa Data t l l�r.{�Conlrxlor fi
ARCHITECTDECIA ATION
f¢� I Understand my plans shall he used as public records
JdU
yap r^ Licensed Professional
5 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt frim the Convacmfs License Law for the
Oo following reason.(Section 7(BI.5,Businessand PmfeuiOU Code:Anycity or county
m which requires a permit to cnuwct,alar,improve,demolish,ar¢pan any machine $2500
prior to its issuance.also refuine,the applicant for such permit no Ole a signed statement
?¢< that he is licensed pursuant m the pmvisiou of Ne Commaur's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
E (commencing with Section 7000)of Division 3 of the Business and Professions Coda or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70315 by any applicant for a permit subjects the applicant a civil penalty of Occupancy Type
nor mo¢than rive hundred dollars($500).
1.as owner of the propcny,or my employees with wages u chub sole compensation,
will do the work and the mumme is not intended aroRcmd formle(Sec.7(A4,Business
and Professions Code:The Contractor's License Law does of apply to an owner of Required Inspections
progeny who solids of improves thereon,and who doessuch work himself ter through his
own employees,provided thm such improvements are not intended OfORered for sale.If.
builder.doe bvl the or thuimpmvement is saldwithin ot year ofcompletion.Neowner-
builder will have Ila burden improvement
ement i that he did ren build or improve for purpose of
sale.).
1,as owner of the pfoprny,am exclusively contracting with licensed contractors 10
construct the es not (Sec.o an Owner
of and property
who Professions Code:)The Convenor's Lid
w osc Law dors not apply w m 0ith a of pmpmy wcensedds Or improves thea0n and.
whocontractsLaw. for such projects withacontncwr(x)licensed pursuant wthe COntraaoh
License law.
❑ lam exempt undo Sec. .Bk PCfor this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under penalty of perjury one of the following declarations:
I ham and will maintain a Ce hifwte of Consent in self-insure for Worker's Cumpcn-
mrion,u pmvidW for by Section 3700 of Ne Labor Code.for Ne performance of the
work for which this panni,is issued.
711 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,for be performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance camicr and Policy number art:
Carrier.��iat-I-0A6[�— Polity No.:nt�U 4--��
CERTIFl— C Of�E FEXEMMON FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed Lithe,permit is forme,hundred dollars(SIM)
or less.)
11.11Rv that in the performance of the.,it for which his permit is issued.I shall not
employ any person in any manna an as to become subject to the WorkrUc Compcuxfiun
Laws Of C31ran ia.Dat
Applicant
NOTICE TO APPLICANT:If.after making this Ccrorcat of Exemption,you should
become subject to the Worker's Cnmpcnsmion provisions of the"hot Code,you must
.JQ forthwith comply with such provisions rar Nis pe.it,hall be deemed rtv.ktd.
Z " CONSTRUCTION LENDING AGENCY
I herehy affirm that Vert is a construction lending agency forth performance of
2' the work for which Nis permit is issued(Sec.301 Co.C.)
D]Q tablet's Name
z Lender's Address
U Q 1 minify that 1 have read this application and shot that the above information is
Iy P coven.I agrte to comply with all city and county Ordinances and sum laws relating to
OU building construction,and hereby autharife mptesenutixis of this city 10 enter upon the
r W above-mentioned property rot iaspection purpmea
y (Wc)agree to save.indemnify and keep harmless the City of Cupertino against
ifA liabilities,judgments.costs and exp resca which may in any way accmc against mid City
U in eonuquencc of the granting of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -_-� '-��
SOURCE REGULATIONS. KISS
�e.1�.�'?sK, cz Re-roofs
Signature of ApplicaHAZARDO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building occupant nomor handle Health
material
u defined M1y the Cupertino Municipal Code.Chapter 9.11,and Nc Health anJ Safety
ode.Section 25331(a)? 0Wl All roofs shall be inspected prior to any roofing material being installed.
❑yes
' If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicm,or future building o .,Of use equipment or devices which
it harafdnus air contaminants u defined M1y Ne Bay Arta Air Quality Manegcmc^, all new materials for inspection.
District? —
bVea IT1Pu '
1 hartmad Neh,a msmaterials5533m cn5under Chapter6.95ofthe Wilding
bite Health&Safety Cade,Scetiou U505.25533 am125534.1 undersand lRuif Inc building
dors roe,cufmnlly hate n,bane that it is my rupouibilitY w nmifY the acupen,of the
¢quire na whmhm eemet Morwiaua co(a Ccmricamufacupancy. Signature of Applicant Date
.9 1 t J d5 All roof coverings to be Class"B"or better
Owner tar ambmiud agent Date
Community Development
10300 Torre Avenue
!1 / Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
oZ14 e Ja ? 0 (0 (
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR n� FAX # / J
I am not using any subcontractors:
Signature `S— 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
C
Owner/Contractor Signature Date
et, CITY OF CUPERTINO
SCM. REPIPE/SEWERS/MAIN SERVICE
'Z1 U I
$CUPERTINO PERMIT APPLICATION FORM ° C7
APN # z 4:, 2— t n 2S Dai./
Building Address-
/ 2
Own is Name: UPhone#:
tractor: nPho�e�: License#:
o ala /zd?S 727-9f'-§G 33
onta Phone: Cupertino Business License#:
=9P3s�
Building Permit Info: — /
Bldg ❑ Elect El Plumb LAY
Job De ription
P L * Z o
Residential Commercial ❑
Cost of Pr, 'ect:
S6O
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
�S� �S