11110128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6367 MYRTLEWOOD DR CONTRACTOR'. _ PERMIT NO: 11110128
OWNER'S NAME: CHEN YUAN-SHIN AND HUNG WAN-YU ,S .t 4-Ae— DATE ISSUED: 11/22/2011
O NER'S PHONE: 5105997194 1 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION (- r r
/, BUILDING PERMIT INFO: BLDG ELECT " PLUMB
License Class G' 7-0 Lie.# !06098719
MECH r RESIDENTIAL r COMMERCIAL ri
Contractor 45916 ///1// Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPAIR FURNACE&RELOCATE TO ATTIC REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professions DUCT
Code and that my license is in full force and effect., WORK
1 hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$6500
permit is issued.
APPLICANT CERTIFICATION APN Number:36917002.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9,18.
Signature140?f Date ZZ �� Issued by:
OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that l am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the fallowing two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I stare or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as de0ned by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this cenificate of exemption,I '/�
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized aggar-�
forthwith comply with such provisions or this permit shall be deemed revoked. ,/� Date-
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
0allend expenses which may accrue against said City in consequence of the
g of this permit Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
• CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36917002.00
DATE ISSUED. . . . . . . : 11/22/2011
RECEIPT #. . . . . . . . . : BS000015383
REFERENCE ID # . . . : 11110128
SITE ADDRESS . . . . . : 6367 MYRTLEWOOD DR
SUBDIVISION . . . . . . . '
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHEN YUAN-SHIH AND HUNG WAN-YU
ADDRESS . . . . . . . . . . : 6367 MYRTLEWOOD DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ABS HEATING & AIR C
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1. 00 41.00 0. 00 41.00 0. 00
1BCBSC VALUATION 6, 500. 00 1.00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 6, 500. 00 0.65 0. 00 0 .65 0.00
1MFR=<100 UNITS 1. 00 130.00 0. 00 130 .00 0. 00
1MPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00
1MRRAA UNITS 1. 00 65. 00 0. 00 65 .00 0. 00
1TRAVDOC FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 325.65 0 . 00 325 .65 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 325.65 VISA
---------------
TOTAL RECEIPT 325 .65
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
• ADDRESS: 6367 myrtlewood dr. DATE: 11/22/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $6,500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK relocate furnace add new duct work throughout sfd.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $130
Heating System 1MRRAA 1 # $65
TOTALS: $195.00
Meeh. Plan Check 0.0 hrs $0.00 11;nnrb_Plan Cluck tile..Plan
Mech.Permit Fee: IMPERMIT Plunrb. Paro,it Pke: .Vlec. Perntiz Pere:
• Other Meeh. Insp. 0.0 hrs $44.00 Other P1umh hrcp. Other E;er.. Drrn.
Mach..Inv). F'ee' Phunb. Imp. Pee, Elec. Inv). Fee, El
NOTE: This estimate does not Include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelindna information available and are only an estimate. Contact the Dear for addn'l info,
FEE ITEMS(Fee Resolution 11-053 Ejj 7/1111) FEE QTY/FEE MISC ITEMS
111an Check Fee:
Supptl. P(.:.Fee
PME Plan Check: $0.00
Perrnir 1,ce:
Suppl. Insp lee
PME Unit Fee: $195.00
PME Permit Fee: $44.00
Construction lits
Administrative Fee: (ADMIN $41.00
Work Without Permit? Yes (E) No $0.00
A,h1Mnced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $44.00 A
Strong Motion Fee: IBSEISMICR $0.65 Select an Administrative Item
• Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $325.65 $0.001 TOTAL FEE: $325.65
Revised: 10/01/2011
I I i 0 zg
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 M I
•CUPERTINO (408)777-3228 • FAX(408)777-3333• buildina(Gdcuoertino.org
SC
UMBING R<CHANICAL ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS L� APNM
OWNER NAME ;!/2Ste/ /9y E-MAIL IJC�`
STREETADDRESS � CITY,STATE.ZIP / FAX
� FA
CONTACT NAME , ` PHONE C•' �/- q/f� E MALI. M•
STREETADDRESS33 'T OG� \' CITY,SFATEy Z@ !D FAX
OWNER ❑ OWNER-BUILDER. ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARc Enver ❑EscoNEER ❑ OEYFIDPER ❑TENANT
CONTRACTOR NAME ) // LICENSE NIIMHEIt�.�. e 70 LICENSE TYPE .ZD BUS.LIC e
COMPANYNAME / � _ A-G E-MAIL f7l�9 FAX
STREET AnnREss JoQ cm,STATEZ23 eHGNR
ARCHITECTIENGINEEINAME LICENSE NUMBER BIDS.IICN G
COMPANY NAMEE-MAIL FAX
STREET ADDRESS CRY,STATE.ZIP PHONE
OF mOUPLEX [3 MULTI-FAMILY PROIECTINWIDIAND ❑ YTS PROJECTIN ❑YTS IS THE BLDG AN ❑YES
NO: 13 COMMERCIAL URBAN INTERFACE AREA NO FLWOZONB ❑NO FICHLER HOME? 0 N
OESCRIPTJON OF WORK �
!i GG ✓G
TOTAL VALUATION: 6,152269 RECEIVED BY: ZZ
By my signature below,l certify to each of the followft. I am the property owner rn aothoriud agent to act ou the property owner's behalf i have read this
application and the information I have provided is correct j have read the Description of Work and verify it is accurate. I agree to comply With all applicable local
ordinances and state laws relaring to buil ' struction. I eatbarize reptesmtatives of Cupa tmo to enter the above-identified property for inspection pullroses.
Signature of App6canVAgenn' Dam: ��'
SUPPLEMENTAL INFORMATION REQUIRED OFFICE Use ONLY
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 4%of. PERMIT# /// l2
OWNER'S NAME: 3 PHONE# G30 /7
GENERAL CONTRACTOR: &.,,,� 1 / BUSINESS LICENSE#
ADDRESS: 33V N O CITY/ZIPCODE: e2
*Our municipal code requires all businesses workin in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum /Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date