07110161 CITY OF CUPERTINO ` ' ' �������
��UILDING DIVISION PERMIT ���1�`f��(T�-�. !
, :,_. _ _ . ..;._ .
:.:: _ ...;: _ ..:,.
PERMIT NO.
su► �� ► � c � n B pR �AZELBROOK DR JEREMY PZAO INC 07110161 .
OWNER'S NAME: � �� DA �
LEAGONG CHEN & CHIWEN L 1041 WITJDSOR ST � 11/29/2007
�NE: SAMTARY NO. CONTROL NO.
(408) 4�69-9942
ARCHI'IECCBNGiNEER: 8UILDING PERMITINFO
BLDG ELECT PLUMB MECH
� 0 0 0
u p p LICENSED CON7RACCOR'S DECLARATION JOb DCSCT1pL10I1
V ► hcrcpy aflirm that [ am Iiccnscd undcr provisions of Chaptcr 9(commencinb
�� wiW SccGon 7000) o( Division 3 of ihc Busincss and Protcssions Codc, and my liccnsc is T EM P P �L �ER
?� y in full fo�a and effect. `�
n �j z Licenac Class l.ic. M
F �p ps� Contrarmr
�+� RCH[7ECI'S DECLA O
��< [ un cruand my ans shsll bc wcd as public rccords
n�.
`� y Licensed Pcufessional
y � OWNER-BUILDER DECLARA'CION
1 hcreby aCfirm tt�a� 1 am e�ccmQt Crom ihc Contractors Liccnse Law for thc
p O following rcason. (Scction 7031.5, Business and Profcssiaas Calc: Any ci�y or county
K,°, Pi which rcquires a pemiit to consuuct, aller, improvc. demolish, or repair any suucwrc
y Z} prior W its iscuancc, also rcquires thc applicant 1'or such permit ta filc a signcd sutcmcn�
_< tha� he is liccnsed pursuant lo Ihc pmvisions of thc Conuactor's Licensc taw (Chap�cr 9 ; iq. Ft. Floor Area � 2 O O Valuation
� F- $(commcncing wi�h Section 7000) of Division 3 of �hc Busincss and Profcuions Code) or
y �.. tha� he is exemp� thc�etrom �nd the buia Cor �he aUcgcd exemption. Any violatian of
Section 7031.3 by arry applicant for a permit subjecu the applicant to a civil penalty of 3 2 6 2 8 0 4:�� Number Oeeupancy Type
not mme tlun five hundmd dollars (5500�
❑ i. u owner o[ the pmperty, a my employces with wages u the'v sole compensation.
will do �he work, and �he suuctwe is not intended or oReced for aale (Sa. 7044. Business Re uired Ins ections
and P�ofessiona Code: The Conuactors License Law doet not spply w an owner of Q P
property who builds or improves �hereon, and who does such work himself or through his
own employccs, providcd that such improvementa ue not intended or offered (or sala I[.
hawever, the building or improvement is soid within one year of completion, tlrc owner-
builder will have �he Durden oC proving �hat he did no� build or improve (or purpose of
sakJ.
❑ I, u awner of the property, am acclusively conuacting wi�h lianaed rnnuacmrs w
consuua ihe peoject (Sec. 7044. Busin�ss and Professions Code:) 7he Coatractnr's Li-
cense Iaw docs not apply a an owner af property who builds or improves ihe¢on, and ,
who conuacts for such projects with a conuactor(s) Iicensed pursuant to the Convactors
License Law.
Q 1 am exempt under Sec. , B� P C for this rcason
Owner Date
WORKERS COMPENSA'I70N DECLARAT[ON
1 hereby aflirm under penalty o[ pe�jury one of �he follawing declanGons:
,� ! hsre and will maintain s Certificate of Consent to self-insum for Workcrs Compen-
sation, as providcd fm 6y SecUOn 3700 of �he Iabor Code, for ihe performancc oC the
woric for which Ihis permit is issued.
❑ I havc and will maintain Workcr's Compensation Insunnce, as �cquired by Scction
3700 of the Labor Code. fw the performance ot the work tw which �his permit is issued.
My Worke�s CompenaaGon insutance cartier and Policy number aze:
Grtiu: Poliry No.: Z �
CE IFlCA OF EXEMPITON FROM WOR RS'
COMPENSATION INSURANCE '
(This section need not bc comple�cd if the permit is for onc hundmA dollua (f I00)
or Icss) '
i cenify U�at in thc performancc of t6e work for which ihis permit is issued, ! shall nol
anploy any pecson in any manncr so u w bccomc mbject w �he Workcrs' CompcnsaUon
Laws of Califamia. Dam
AppGcmi —
NOT(CE TO APPLICAM: If, allcr making �his Ccniticstc of F�ccmpGan, yau shauld
barome subjctt to �c Warker's Compensation provisions of the Lalar Codc, you must
� O fortMwith camply with such provisions w this permit shalL 6c dcemed mroked
z ""' CONSfRUCT(ON LENDING AGENCY
[– � t Mfcby �rm Nat thcre ia a consuuctinn Icnding agcncy (or thc perCortnance of _
p�„ � the work (or which this pertnit is issued (Scc. 3097, Civ. C.)
W� Q Lendcr's Namc '
� z L.ender's Address
() � I certiCY Uut 1 have resd tlds application and suic �As� the above informatiun is
w�' cortcc� 1 sgrce w comply wi�h all city and counry ortiinances and sute laws celadng to
� U building consuuction, and hercby amhori�t reprcsentadvcs of �hu city to cmer upon Ihc
� a abovo-menuoned propcny for inspection purposes.
(Wc) agree to save, indcmnify and keep harmless ihe City of Cuperdno against
�� Iiabilitiu, judgmcnls, cosLt and expenacs which may in any way ucruc against said City
V z in consequence ot ihc granling of this permi6 i� Q
�"� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date , � Q��
SOURCE REGULAI'IONS.
Re-roofs _ /
Signuuro o( Applicant/Contracar Datc �L��
HAZARDOUS MATERIALS DISCLOSURE Type of R )Of
w II thc applicant w futwz building occupant storc or handle hanardous matcrial
u defincd by Uu Cupertina Municipal Code. Chap�cr 9.12. �nd che Hcal�h and Safcty
c«k SccGon 25532(a)? All roofs : hall be inspected prior to any roofing materiat being installed.
❑ Ycs �o
Will U�c applicant or fuwm building occupant usc cquipmcnl or dcvices which
If a roof i: installed without first obtaining an inspection, I agree to remove
�it har.udous air conuminan�t u dcfincd by Ihc Bay Area Air Quality Managcmen� all new m, �terials for inspecr_ion.
U13V1���
Q Ycs Of7(No
Ihavcrcaclihehvacdcws`aicrialsrequiremcnuundcrChap�cr6.95of�cCalifor- T��•��� ' ^
nia FIcal�h & Satcty Cadc, Scctions 75505, 25533 arol Z5534. t wdcrsund thati( Uu building � J� ,G/Lv'
docs no� curtenUy haw a tcnan4 ihat it is my msponsibiliry m notiCy U�c occupant nf the
rcyui�emcn�s which must ut priorm usuance ota Certificaic o( ccupancy. Signature �f Applicant Date
y � � �, �' All roof coverings to be Class "B" or better
Owner or autt r'v.cd agcnt !6a1c
CITY OF CUPERTINO
4 ITEMS OF 4 PERMI7' RECEIPT OPERATOR: patg
COPY # : 1
Sec : Twp : Rng : Sub : Bl]�:: Lot :
APN ......... 32E28049.00
DATE ISSUED.......: 11i29/2007
RECEIPT #.........: BSC�00003353
REFERENCE ID # ...: 07J10161
SITE ADDRESS .....: 21]05 HAZELBROOK DR
SUBDIVISION .......
CITY .............. CUF'ERTINO
IMPACT AREA ......:
OWNER ............: LE�,GONG CHEN & CHIWEN LU
ADDRESS .... ......: 21�05 HAZELBROOK DR
CITY/STATE/ZIP ...: CUF'ERTINO, CA
RECEIVED FROM ....: JEF:EMY H MAO
CONTRACTOR .......: JEF:EMY HAI-PING MAO LIC # 26422
COMPANY ..........: JEF:EMY MAO INC
ADDRESS ..........: 10�1 WINDSOR ST
CITY/STATE/ZIP ...: SAP� JOSE, CA 95129
TELEPHONE ........: (4(�8) 449
FEE ID UNIT QUANTITY �,MOUNT PD-TO-DT TI-IIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 200.00 0.50 0.00 0.50 0.00
1EPERMITFE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
1ERT>1K UNITS 1.00 71.39 0.00 71.39 0.00
1TR.AVDOC FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 153.47 0.00 153.47 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 153.47 VISA
---------------
TOTAL RECEIPT : 153.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
304 ROUGH ELECTRICAL 402 TEMPORARY POWER
505 FINAL ELECTRICAL
o���a�c��
CITY OF �CUPERTINO
- ` ` � TEMP POWER
CUPEtj�TINO PERMIT APPI,ICATION FORM
APN # Date:
� a� a� o�9� o v � r`��r °�
Building Address:
Z I 1 C,S ��4 Zc L,���t� �k -
Owner's Name: Phone #:
�t-� C�v�'y c:i��r1✓ �' ��f�W��ci' Lu� rf�L _ ��7- �3�L�
Contractor: Phone #: y�v� .-���- yy¢Z
,� EP•�tii � �-t.4v i•rr� , .�.�� - �L� � �33��
Fax #:
Contact: Phone #:
����'�� �� 4�� �'�, J �Y�
Contractor License #: � - ��3 ¢S Z
Cupertino Business License #: a �
Job Description:
Residential � Commercial ❑
Valuation: � �
. 2ov `�`
Qty. if
A licable Fee ID Fee Description Fee Group Permit Type
� ERT>1K � Res. Temp PowE.r >1K Amps ELECTRIC REAP14
ERT<200 Res. Temp PowE:r <200 ELECTRIC
Amps
ERT2001K Res. Temp Powf 200-1K ELECTRIC
Amps
/ EPERMITFEE Electric Permit I�suance ELECTRIC
/ i
ELCPLNCK Electric Plan Ch ;ck ELECTRIC
� BSEISMICRE Seismic Residential BUILDING
✓
BSEISMICOM Seismic Comme-cial BUILDING CEAP14
,
CITY OF C �
TEMP �'OWER
CUPEi�TINO PERMIT APPLICATION FORM _.
BPWSVCS Water Service PLUMBING CPWS or
RPWS
PPRSEWG Private Sewage Di:�posal PLUMBING
System
PCESS Cesspool PLUMBING
BPWATER InstalUalter Water J'ipe PLUMBING
BPFIXTURE Plumbing Fixture PLUMBING
PGASRES Residential Gas Pi��ing PLUMBING
System 1-4 Outlets
BPGAS Gas Piping System 5+ PLUMBING
Outlets
PPERMITFEE Plumbing Permit F�e PLUMBING
Issuance
PLMBLNCK Plumbing Plan Che ck PLUMBING
PLMBINSP Other Plumbing/ga� Insp. PLLTMBING
TRAVDOC ✓ Travel & Documer. tatiori Fee BUILDING
BUSLIC Business License BUILDING