07100120 CITY OF CUPERTINO � ' r : > ' " '
• BUILDING DIVISION PERMIT �*���� �T��Z�����TIQ� ` '
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PERMIT NO.
BUIL alr��r�o�es� pORTAL AVE WELKIN .CNTERNATIONAL IND 07100120 .
OW NER'S NAME: PE[tMIT ISSUE DATE
LI, HOWARD 19925ST:�VENS CREEK BLVD' 10/17/2007
�NE: SANITARY NO. CONTROL NO.
(408) 73:3-0188
ARCHII'ECT/ENGiNEER: BUILDING PERMIT INFO
BLDG ELECf PLUMB MECH
� 0 0 0
i p p LICENSED CONTRACTOR'S DECLARATION JOU DCSCiIp$011
� V� I hercby aCfirm that I am liccnscd undcr provisions of Chaptcr 9(commencing
, z� with Scction 700U) o(Division 3 of ihc Busincsc a�M Prafcssions Codc and my license is TEMP P01 VER F OR NEW S FDWL
���a„ in full fose and eCfec�
� ,� ? Licensc Class Lic. #
; F , � Datc Coniractar
� ARCHCfECTS DECLARATION
7 d e I undcrs�and my plans shall bc uxd az pu6lic records
)aU
' u. y Licensed Pcofcssional
� y � OWNER-BUtLDER DECLARATION
t hcrcby alTirm that 1 am excmpt Crom ihc Contractor's Liccnsc Law Cor thc
� p O (ollowing reason. (Scction 7Q3I.5, Busincss and Profcssions Ca1c: Any city ar county
�,°, � which rcquires a pcimit to conswct, altcr, improvc, dcmolich, nr repair any swctucc
� Z y priar u� i�s issuancc, alsu rzquires the applicant for such pcnni� io filc a signcd stalrmcnt
�_< �hat hc is IiccnscJ pursuant lo thc provisions af thc Comracmr's Liccnsc Law (Chapicr 9 ,>q. Ft. Floor Area � 5 O O Valuation
� F- �(commencing wiih Section 7000) of Division 3 of Ihe Business and Professions Cade) or
L�� that he is exempt Ne�cfrom ond the buis Cor the allcgcd exemption. Any viotaGon a[
Section 7031.5 by airy applicant for a pecmit subjecu ihe applicant to a civil prnalty of 316 2 9 0 0��� Number Oeeupaney Type
not more than fiw hundred dollars (5500).
❑ I, u owncr oC the property, or my employces with wages u tlx'v satc compensatlan,
will do thc work, and the sccunum is rrot intended or aBered for sak (Sec. 7044, Businas Re u ired Ins eCt1011S
and Professions Cade: The Conuactar's License Law daes not apply w an owner of Q P
propeny who builds or imptoves thercon, and who dots such work himsel[ or theough his
own employccs, provided U�at such improvemenls are noc intended or otCered Cor sak. [f.
however, �he building or improvement is sold within one year of complcdon, ihe ovvner
buitder will have ihe burden oC proving Wat M did not build or improvc for puryau o(
saleJ.
. I, as owner of the propeny. am eacclusively conuaeting wiW Iiansed contnctars m
conswct the projea (Sec. 7044. Business and Protessions Code:)'Ihe Cootractars Li-
ccnse Law docs not apply to an owner of property who builds or improves tAe�eon. and . -
who conuacts for such projects with a convactor(s) Gcenaed pursuant m tLe Conuactors
License Law.
❑ i am aempt u Ei Sec . B& P C for this ressoa
Ownv Date _� j�� _ . -
ORI COMPENSATTON DECLARATION
1 hereby aflicm under penalty of perjury onc o( the fotlowing declaratianx
❑ i hsve and will maintain a Certificatc of Consent to ulf-insure [or Workcrs Compen-
sation, u provided for by Sectian 3700 ot the Labor Code, far �he performan¢ oC �he '
work for whicd this permit is issucd.
❑ I have and will maintain Worker's Compensation Insunnce, as syuired by Scction
3700 of the Labor Code. Cor the performance af the worlc for which �his pe�mit is issued.
My Worku's Compensation Insurance cartier and Policy numbcr are:
Camer. Policy No.:
CERTiFICATE OF EXEMPI'!ON FROM WORKERS'
COMPENSATIONINSURANCE •
(ihis secGon necd not hc complctcd if the pertnit is for onc hundred dollus (Sl�
or Icsa) '
1 certify Ihat in thc performancc of ihc work for which U�is permit is istucd. I shall na
employ any person in nc so omc b' Workcrs' Compenvtion
Laws ol Califomia
Appticant
NOTICE TO C,IEA , aftcr making tNis CcniGca�c o! EzempGon, you should
bccome subj �hc Worker's Compcnsation provisions of �c Latior Codc, you must
, O forthwi�h compty wi�h such provisians or this pecmil shall bc dccmed rt.wakcd.
z ""' CONS'fRUCTtON LENDING AGENCY
F r ►�-� I hemhy alTirm that thcre is a consuuction Icnding agcncy for thc perfortnancc of
Cli � ihc work for which Utis permit is issued (Scc. 3097. Civ. CJ
W� Q Lendcr's Namc •
� � L,cnder's Address
V Q 1 certify Uia� I havc rcad this application and s�atc tha� thc above infocmation is �
� �" wrrcct. I agree to comply with all city and county aretinantts and state laws eelating to
� U building conswction, and hercby authori�e reprcsentativcs of ihis city to cntcr upon �lic
� W abovc-mcntioncd property for inspccuon purposes.
a (Wc) agree �o save, indcmnify and kecp harmless ihe City of Cupcnino against
„H � liabili[ics, judgmcnLt, costs and expenses which may in any way accruc agains� said Gty
V z in consequence tAc granung of Ihis permit. DSLE
►'� APPLICA UNDERSTANDS AND WILL COMPLY W[TH ALL NON-P�IIYI' Issued by:
SOURC EGU NS. ��� / O /� /
/ -"�' -.�-v' � d Re-roofs
Si of Applicanl/Conuactor Date
HAZARDOUS MA7'ERIALS DISCLOSURE Type of R�of
Will ihe applicant or futurc building acupant storc or handlc harardous matcrial
az dcfincd by thc Cupenino Mu 'cipal Codc. Chaptcr 9.12. and thc Hcalth and Safay
Calc, Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
� y� No
Will thc applicant or futurc building occupant usc cyuipmcnt or de+ricrs which . If 3 rOOf I installed without first obtaining an inspection, I agree to remove -
cmii harardous air contaminan�c u dcfincd by the Bay Arca Air Quality Mmagcmeai all new m. iterials for inspeetion.
��s�c�?
❑ vcs u
1 havc rc e hvardous atcrials requircmcn�s undcr Chaptcr 6.95 0( thc Gli[w-
nia Hcalth & 5 y Codc, Sccuons 25505.25533 anJ 25534.1 undcrstand thaz iC�hc bdlding
does noi cu ntly ha���'''��� a �enan4 lhat it is my responsibility m nodl'y the occupant of �he
rcyuircm wh n �q45t be m l prior ta issuancc oCa Ccnificate of Oc �r Signature �f Applicant Date
�
All roof coverings to be Class "B" or better
O r or aulhorized agcnt � �
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIr RECEIPT OPERATOR: patg
' COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 31629004.00
DATE ISSUED.......: 10/17/2007
RECEIPT #.......... BS000003008
REFERENCE ID # ...: 07100120
SITE ADDRESS .....: 10314 N PORTAL AVE
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OWNER ............. LI, HOWARD �
ADDRESS ..........: 10314 N PORTAL AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-2351
RECEIVED FROM ....: LI HAOTAO
CONTRACTOR .......: XIE, CAIXING LIC # 24081
COMPANY ..........: WELKIN INTERNATIONAL IND INC
ADDRESS ..........: 19925STEVENS CREEK BLVD
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........: (408)733
FEE ID UNIT QUANTITY �'IOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BTEMP FLAT R.ATE 1.00 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 102.89 0.00 102.89 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------•----------- --------------- --------------------
CREDIT CARD 102.89 MC
---------------
TOTAL RECEIPT : 102.89
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
_�' CITY OF CUI'ERTINO � 7( � n���
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CUPEf�TINO PERMIT APPLICATION FORIVI
�PN # Date:
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Building Address:
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Owner's Name: Phone #:
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Contact: Phone: / Cupertino Business License #:
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Building Pei Inf .
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Job Description:
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Residential Commercial ❑
Cost of Proj ect:
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Qty. if
Ap licable Fee ID Fee Description Fee Group
) BTEMP Tem orary Power ELECTRICAL
� EPERMITFEE El.ct. Permit Issuance ELECTRICAL ,
BUSLIC Bi�siness License BUILDING ;
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