02030045- PUB P
LL-
0 Q
v
L)
Ir U a_ t
N a D ' m a �'
�Z ,vp 0 ai v N 0 0 0 > D o =°
O m �rU w 0- a = U c) O v, _z a
v
a�
D
_0
LO Q
m
oa
v
0
LO
CT)
0
Z
W N
U o
7 0
~ cF I
U ~ 0 W --I
w Uo
m a N
Q O
Z
Z Z o ca r,
CO v w l --4 A
Iro Z v w vv, tr pq
N W N W 0 ZD 0H
�v U
� SL ❑ 2 r 1 9
a) = z f
6
Lo
c U)
z E- v -0 a
a0 ¢
Idl
v v L
o 'c D
O O W
71 x0
Z 007 N N U IV I IV I icri
_a %Y a O. 0. O
v O O O O
_ �{• OO f� D
"L Ld
H
_ o 7tI.I 2
LO LD LO U
i
O. wLD
o } o w
`4 .. LO o O O CTI Q z Z 0
U-
M W
- O O J O J iJ7 W m
J
J o c~v 0 0 Z J LLJ
Vi O 1 l 1 LL O J w
C�jO O M T m O 0 � Q *-CD N
d 2' a) O
v -0 4] 41 x 3 v N
x v v -0 Cl N v v OL
0 _ xN a y
o N a � ° xa +o �` v ~ xE a m` o
E xv Z a� a v 7 w v o o f in
fu OL
v v —'' a� v N a O 7v LO
=' w +o o a a`) a`r a`r a� E Z d cn U Z CL O 0- a
-� 0- to :2 0- Q 0- U U U a�
CITY OF CYJPEd2T'gN®
BUILDING DIVISION PEj`R�/ RT CONTRACTOR ® ► AT
BUILDING ADDRESS: PERMIT NO.
21724 REGNART CT 02030045
OWNER'S NAME: APPLICATION SUB DATE
KENNETH & BETTY CHENG 03/12/2002
PHONE: SANITARY NO. CONTROL NO.
O C z ARCH ITECTIENGINEER: BUILDING PERMIT INFO
WOO BLDG ELECT PLUMB MECH
<�
w Z LICENSED CON'TRACTOR'S DECLARATION Job Description
i z CI hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code.and my license ADD 417 SQ. FT.
is in full force and effect.
wu< License Class Lic.#
a U Date Contractor
O ARCHITECT'S DECLARATION
hy j I understand my plans shall be used as public records
m>
1 r p O Licensed Professional
x o F� OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
[—Z>' following reason.(Section 7031.5,Business and Professions Code:Any city or county $55000
FZ-C which requires a permit to construct,alter,improve,demolish,or repair any structure
a 3 GO prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to,the provisions of the Contractors License Law(Chapter 9 }-
(commencing,with Section 7000)of Division 3 of the Business and Professions Code) , .3��•2L}( �r 1 .. Valuation
or that he is exempt the' from and the basis for the alleged eieinPtion.Any violation
of Section 7031:5-by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500). 10 CPN DAT I ON Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.70.14, - - --
Business and Professions Code:The Contractor's License Law does not apply to an 103 - UFER Required Inspections
owner of property Who builds or improves thereon,and who does such work himself _ 1 0 4 — REBAR
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 105 — ANCHOR BOLTS -
completion,the owner-builder will have the burden of proving that he did not build or '
improve for purpose of sale.). 106 - SEWER & WATER
Las owner of the property,am exclusively contracting with licensed contractors to 202 — UNDERFLOOR PLUMBING
c nstrvct the project(Sec.7044,Business and Professions Code:)The Contractor's 203 — UNDERFLOOR MECHANICAL
License Law does not apply to an owner of property who builds or improves thereon,
and who contracts forsuch projects with a contractor(s)licensed pursuant to the - 2 04 UNDERFLOOR' FRAME - - - -
Contractors License Law.
❑I am exem t under Sec. B&P C for this reason 205 — UNDERFLOOR INSULATION
\C6wner / 301 — ROUGH PLUMBING
�1 RKFR'SCQWP ATIO D C R T N 302 — TUB & OR SHOWER
I hereby affirm under penalty of perjury one of the following declarations:
303 — ROUGH MECHANICAL
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's 304 - ROUGH ELECTRICAL
\J Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued. 305 — FRAME
❑.I have and will maintain Worker's Compensation Insurance,as required by Section 306 — HOLDOWNS
3700 of the Labor Code,for the performance of the work for which this permit is 307 — INSULATION
issued.My Worker's Compensation Insurance carrier and Policy number are:
Carrier.�� �� � � I' ' ( 'Policy No.:
308 , SHEETROCK
CERTIFICATION OFEXEMPTION FROM WORKERS' YO 9 , EXTERIOR LATH
-COMPENSATIONINSURA34CE_
31-0 INTERIOR
(This section need not be completed if the permit is for one hundred dollars 311 - SCRATCH COAT
($100)or less.)
I certify that in the performance of the work for which chis'permit is issued,I 313 — ROOF -NAIL- - - -
shall not employ'any person in any manner so as to become subject to the Workers' 501 - F I NAL ELECTRICAL ENERGY
Compensation Laws of Califomia.Date '
Applicant - 502 RINAL PLUMBING ENERGY
,NOTICE TObj APPLICANT.,the Worker' after ranking this Certificate of Exemption,you should 503 - F I NAL MECHANICAL ENERGY
Z become subject to the Worker s Compensation provisions of the Labor Code,you must
O C) forthwith comply with such provisions or this permit shall be deemed revoked. 504 — .FINAL BUILDING ENERGY,
F 'CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
1 hereby affirm that there is a construction lending agency for the performance
W a o(thework for which this permit is issued(Sec.3097,Civ.C.) 506 — GAS TEST
A Lender's Name -
�_z Lenaer'sAdaress''„ 507 FINAL PLUMBING
wO 1 certify that 1 have read this application and state that the above information is 508 — FINAL MECHANYCAL
E.t cored.I agree to comply with all city and county,ordinances and state laws relating 509 - FINAL GRADE
® to building construction,and hereby authorize representatives of this city to enter upon
the above-mentioned property for inspection purposes. 510 - F I NAL PLANNING
E.t Or (We)agree to save,indemnify and keep harmless the City of Cupertino against
., V] liab lilies,judgments,costs and expenses which may in any way accrue against said 5 1 4 — F I NAL PU I C WORKS
HCity in consequen the granting permit.
R — V
APPLICANT STANDS ANDD WILL
LL COMPLY ALL Noy-POINT by:S URCE L TI 's. � Issuey: Date
' i Applic onttact r - Date Re-roofs
RDOUS MATERIALS DISCLOSURE
Will the team orfuture building occupant store or handle hazardobs material Type of Roof .
- ag defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? -
❑Yes' t7 No .- _All roofs_shall be.inspected prior to an roof)n
- .:.I p P y. g material being installed..Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
❑Yes, o No all non-point-source regulations.
•�- 1 have read the hazardous materials requirements under�Chapter'6.95 of the
Califomia Health&Safety Code.Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the -
Occupant of the requirements which must be.met prior to issuance of a Certificate of
occupart y/1...1
,
3 LSignature of Applicant Date
Owner or agent D All roof coverings to be Class "B"or better
OFFICE
C%Y OF CJPIERTINO
:SCC.
CITY OF PERMIT APPLICATION FORM
CUPEK rINO
APN# Date:
5c� - Z • - 034- , o 61 t2
Building Address:
2j�ztle
Owner's Name: Phone#:
L/ W N 0o
Contractor: License#:
Cont ct: Phone#: bp -- qq
u ra �v
Ap ica Contractor: Fax #:
SIO l - Z
uildi ermit'Info:
Bldg Elect Plum Cmech
,,job escription:
Residential: Commercial:
Sq.Ft. Floor Area: I $/Sq.Ft.:
A W L�9
Architect/Engineer: Valuation:
DDB
Type of onstruction: Occupancy Grou
J
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permit sq. foot BUILDING
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
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone' BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC 1000 Elec 600V <= 1000A ELECTRICAL
BELEC 1001 Elec 600V > l OOOA ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
� 760"
Iof3 ,L � 1/ 7Y , 2D