06010022 (2) • C ITY OF CUPERTINO �t�,��
BUILDING DIVISION PERMIT
fu ,^,d,' t ,.•.r,`4•.s.TL .Y�ft{.<,.k5 ., tiro, i.?rue,
But
ADDRESS: LIWN LIU PERMITN0.06010022
0240 JOHNSON AVE
+OWNER'S NAME: PERMITLSSUEDATE
LIWN LIU 10240 JOHNSON AVE _____01/05/2006
NE: SANITARY NO. CONTROL NO.
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30j LICENSED CONTRACTOR'S DECLARATION 7obDescription
i� 1 Wmby iam.p.r Nat I am Ihmmd irm provisions of Chapter 9(commencing
wrth Section7d effect. idon3of MC Businw and Profesdou Code.and my license is
n� hmnfomeandertea CHANGE RANGE HOOD B
Z Linen¢elm S a
Date Contractor
IIITIyJyjw�it'
e ARCHDECLARATION
y I understand my phos slWl heTW=it u Public aecorN 1 i
u Licensed Professoriat j(t
+�3 OWNER-exempt RDEMe Com od Bull
0 ON
E 1 hereby 4(Srm that 11. exempt from Me Cssion; o :My c low for the % /(q ,. r
y O O following moon.(Section 7051.5,Business and Nafessium Cade:My oily of county frv/Jj/'Jr h
S$ which mqulmanpeered reeore Me.slten ImProw,h permits me a sig my structure y+..,fy A 400
„ Met
itsissuance.pursarequire dMapplitlnlfof Co mo permit in Rleatiaw(Cstatement u
0 (commencing is cdPunuen7")of ivisio diluted oftheStrcesandPrmisw(Chapur9 Sq.Ft. Floor Area —Valuation
(cwnmendngwith hadefonis ndM Dlvision7 ofthe My
Cnde)car
that he b exempt Ommfmm and de buh far Ne alleged assumption.Any Woladon of
Section 7031.5 by any applicant for.permit subjects me applicant his civil penalty a r Occupancy Type
trot mom dun Rw hundred dollars(55001
❑1,u owner of the property,or my employers with wages as their sole compensation,
will do the work end the mdmurt barred intended oroa red forsaie(Sec.7010,Bulinus
and Profmlo s Code:The Conuanors Liaise law don not apply to an owner of Required Inspections
j mp ury whobuiIds or Improves tilemon,and whodoessohwork himself orthrough his
own employees,provided Mattock Improwmeru are notintended oranered faukif.
however,the building or improvement is mid wimin can year of comphtiot.Ne owner.
builder will have the burden of pmving that he did not Wild or Improv for purpose of
sale.).
❑1,its owner of Me property and exclwively conuaming with Ikeued contraction;he
construct Me Project(See.7044,Bwlnw add Professions Code:)The Container's Lb
am law does act apply to an owner of propeny.who WE"or improves memon,and
who contracts for such projects with a commicu s)licensed pursuant to the Contommes
License law.
❑I am eaemp under Sec. ,B A PC fm Ms mason
OwnerDas j -/O(,
-
cKERSC ENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dalaraUou:
1 haw and will maintain•Certificate of C...I to sel6iuure for Worker's Compen-
aaded,an provided for by Section 7700 of the Labor Code.for the performance of Me
work for which this permit Is Issued.
❑1 haw:and will maintain Worker's Compensation Imusana,as required by Section
5700 of me laWrCode.Aar Me performarce of du wort for which this permit is issued.
My Worker's Compensation Insurance artier and Policy number art:
Cartier, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nerd notheeampleied If 1W pem ll is Attend hundred dollen($IW)
or leas.)
1 moify Not In the im ormam of the work for whi h this permit is Issued,l shall am
emPloyanypeonieO7/.n`y mannerm��bttoMe> Ieclmmeworlo Compemdon
Iawsaf Califund ate C /V
Applicant
NOTICE TO APPLYCANT:1IL after mating MS Certificate of of Labor on,you should
become subjectnothe Worker's CompensationprovisionsA.1 of the IoM Coded. menu
.J Q feMwim comply with such provslou m ms perms shall W domed revoked.
,zt CONSTRUCTION LENDING AGENCY
[•w ice+ Ihemby affirm that there is a construction lending agency for due performance of
C r+Y+ Me work for which this permit is issued(Sec.3097,Civ.C.) '
Q lender's Name
z• Ienderu Add.
U0 I certify that I have mW this application and Nm Mn the show information is
Is, P comet.I agme to comply with all city and county ordinances and sole laws relating to
OU building construction.and herby suthodm represenutivea ofmis city to enter upon Me
[x7 aMvcmentioned property for inquNon PurPous.
gL (We).gra to saw,indemnify and keep harmless Me City of Cupertino against
y. liabilities,judgments,costs and expenses which may In any way accrue against said City
U7 in consequence of the granting of this permit.
t1—
APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NON pDINT Issued by: Date r f JC
SOURCE REGULATION . (/S-(
/S/D G
I Re-roofs
Sign rtof AppliceDDate /Cl
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ed theapplicant car future ni ipal Code.Chapter
hasHealth
eallond Safety u da.Sec n the 32(a)?Cupertino Municipal Code.ChaPur 9.1x.and Me NW N and Safety
cads. 0 Second 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON, i
Will the applicant or future Wilding oavpenl use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
It Nuardous air commom ns as dented by Me Bay Arta Air Quality Management all new materials for inspection.
suiclT
❑Yes 10 No
I haw real the hvardousmauriahaeyuimmenu under Chapur A95ofthe Celi(or,
nu Hpl Sn Cadc,Satisu23505,755]3 wa1215N.lunMastsW Muifdc Wilding
docs not umcmly haw a unto It is my respoulkiliry m notify dte occupant of the
OtswhlCbmuRW hr1.iuumayf.Ccnifuauof7ccu a Signature of Applicant Date
require,' —`� I " �" All roof coverings to be Class"B"or better
Owneror amhorimd.gen r Dam
Community Development
10300 Torre Avenue
l ' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT#
I ZFo jo ko so-t AL/e- I Q 66/ dd2�1
OWNER'S NAME: L, W w L i PHONE # Lw'09-) 8'73
GENERAL CONTRACTOR vi nalr FAX #
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
Owner/Contractor Signature Date
ON
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. All the work authorized by this permit
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.
PersorVF= 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 Owness Signature: c Date:
Job Address: 102JP0 J o k nsoh aJe,- Permit#
AM changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department
City of Cupertino Building Department
10300 Torre Avenue
CU PERTINO Phone: ('106)7;;;A
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 protect yourself 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 titan 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 compensation
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 hwurance
For more specific information about your obligations under federal law,contact tine Inteinal Revenue
Service (and,if you wish,the US.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.
professing tobe contractors is to secure owner boulder
A frequent practice of unlicensed pepersonsbunldmg permit;erroneously implying that the property owner is providing his or her ownn labor and material
personally. Building permits are not required t D be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be 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
P&od on Focyclad Paper
' • _ ? CITY OF CUPERTINO
CITY o
PERMIT APPLICATION FORM G l Z Z
CUPERTINO
N.# 3 rl 5 2-5 o6 2 Date: / /S- 1o6
uilding Address: 1o2,qo �17156n ��e Mailing Address (if different from building address):
Owner's Name: Phone#:
L Www L ti cIto&> &73 - 3 69 j
Contractor: License#:
� � l� n1 vLt/Y•
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect 4D Plumb ❑ Mech ❑
Job Description-
Residential
Residential M &611 e k"J Commercial ❑
Sq.Ft. Floor Area: q,Ft.:
Cost of Proiect: (�o� Occupancy Grouu:
Type of Construction: Y atm9 2 he o Please check this box if the project is a
second-storyaddition: El
ro'ect Size: Standard ❑ Laze ❑ Major ❑
Quant Fee ID Fee Description Fee Group
BAPPLOTHER OtherAppbances 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
BBOMER5 Boiler> 1.75MBtu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTA)MQ 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
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1 CITY OF CUPERTINO
CU EkT
0 PERM PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOM vM New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg 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 rinEer/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstalVAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent 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 Apphance Install MECHANICAL
BREMBUSWAY .. Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> IOK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BRENOMC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power DevicelApparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT -Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEkTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREI%=ATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb S ecific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit I BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERA UME Elec Permit Issuance I ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERNMFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Planibing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Commet Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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