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07080008 CITY OF CUPERTINO BUILDING DIVrSION PERMIT � �� R� pMTI(aN.. PERMIT N0. BUILDjN ADDRESS: y1 FERNGROVE DR K & M DEVELOPMENT INC 07080008 PERMIT ISSUE DATE OWNER'S NAME: CHIN SHAOAN AND GILLIAN 1060 W TILL CT 08/01/2007 SANITARY NO. CONTROL NO. ,VE: (408) 253-9787 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH eC Z LICENSED CONTRACTOR'S DECLARATION Job Description w o I hereby affirm that I am licensed under provisions of Chapter 9(commencing U with Section 7000)of Division 3 of the Business and Prof tons Code,,and my license is TEMPORARY POWER POLE =w in full force and effect. OP Z License Co.S o Datc Contractor IE ARCHITECTSDECLARA ON i a a and tand my plans shall be used as public records yU u H Licensed Professional I y-< OWNER-BUILDER DECLARATION } 1 hereby tiTirm that 1 am exempt from the Contractor's License Law for the I 00 following reason.(Section 7031.5,Business and Professions Code:Any city or coumy "9 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 rile a signed statementgq Ft.Floor Area Valuation ?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $500 h (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 A��l Number not more than five hundred dollars($500). 37539056 I,as owner of the property.of 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 dos 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.). Q L as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractors Li- cense Law docs not apply to an owner of property who builds or improves themon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. Q I am exempt under Sec B do P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (]1 have and will maintain a Certificate of Conscnt to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Q I have and will maintain Worker's 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 C tpensauon Insurance carrier and Policy number Cartier. C n/ j Polity No.: n3 RTIFICATE OF EXEMPTION FRO 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,after making this Certificate of Exemption.you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. 7_2 CONSTRUCTION LENDING AGENCY Er b.) 1 hereby affirm that there is a construction lending agency for the performance of - (1C, > the work for which this permit is issued(Sec.3097,Civ.C.) , W Q Lender's Name a z Lender's Address U 0 1 certify that I have read this application and state that the above information is w correct.1 agree to comply with all city and county ordinances and state laws relating to 'D U building construction,and hereby authorise representatives of this city to enter upon the U above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against CI) liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. Date ►'� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b'r: SOURCE REGULATIO Re-roofs Sig n Date HAZA U MA ALS DISCLOSU E Type of'Zoof Will the applicant futurebuildin oceupantstore orhandle hazardous material as defined by the Cope no Municipa ode.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roof: 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 applicant or futubuilding occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new 1 naterials for inspection. District? 0 Yes 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 tenant,that it is my responsibility to notify the occupant of the requirements which t m crtiftcaicofOccupacy. Signatur-.of Applicant Date U ' All roof coverings to be Class"B"or better r authorize l Da CITY OF CUPERTINO 2 ITEMS OF 25 PERMIT' RECEIPT OPERATOR: CathyS COPY # 1 Sec: Twp: Rng: Sub: B11c: Lot: APN . . . . . . . . . 37539056.00 DATE ISSUED. . . . . . . : 08 /01/2007 RECEIPT #. . . . . . . . . . BS)00002228 REFERENCE ID # . . . : 07 )80008 SITE ADDRESS 921 FERNGROVE DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER CHIN SHAOAN AND GILLIAN ADDRESS 921 FERNGROVE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4664 RECEIVED FROM . . . . : GILLIAN CHIN CONTRACTOR MARTHA KANG LIC # 22244 COMPANY K & M DEVELOPMENT INC ADDRESS . . . . . . . . . . . 1060 W HILL CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : (408)253-9787 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---- BTEMP FLAT RATE 1. 00 62 .10 0. 00 62 .10 0. 00 EPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38.37 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 100.47 0. 00 100.47 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- -------------- 103 UFER 304 ROUGH ELECTRICAL CITY OF C'UPERTINO a TEMP POWER CUPEI�TINO PERMIT APPLICATION FORM :Z2 C G� CPN# 5�'/ Date: Building Address: yz/ ��✓�'� Yt �- Owner's Name: Phone#: Contractor: Phone: I_,icense #: Contact: Phone: Cupertino Business License#: Z 2�f Building Permit Info: Elect ❑ Job Description: Residential Commercial ❑ Cost of Project: Soo Qty. if Applicable Fee ID Fee Description Fee Group BTEMP TE.mporary Power ELECTRICAL EPERMITFEE El--ct. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING