08020192 CITY OF CUPERTINO � *3TM�z+�4 '�+' .�''�'*a"'•'�"" '"t°ba�°�I"'�'��:' ''n`
BUILDING DIV]S ION PERMIT CONTRACTOR I'NF ORM 'ION
PERMIT NO.
BUILDITble9�S5:SHELLY DR TBD — TO BE DETERMINED 06020192
OWNER'S NAAM.IE�: PERMIT LSSUEDATE
ItHO JEAN. 0 AND GILBERT D 02 2
NE: SANRARY N0. CONTROL NO.
ARCHI ECf/ENOINEER: BUILDING PERMITINFO
BLDG EIEC! PLUMB MECH
i0, LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 Mmby.from that 1 am licensed under pmvitia�of Chapel 9(wmmenring
.Zm wiNSection10f1U).fDiviaion3afdteBusineaAndProfrsdamCode.arldmylicrnseu REPLC EXSTNG 100AMP ELC CRCT PANL W/NEW 204OM200C
in full force and Affect. ( J
jq?
License class Lk:.g CIRCT PANL
i f o Dam 3[_ Conlracmr
J
ARC CPS OECI.S ATIO
1 unticramnd my plain shall W used as public rtcnrdr
)yU
°oN Licensed Professional
g MeIamexemptOWNER-BUILDER nt Me on"Clo
} ATION
I hereby Affirm Nm 11. ,Bumps Gum tic Cssions fs License law for the
1 O O rollnwing reason.(Section 11n L5,Business and Profeuinns Calc:Any city ar cemuy
which requires A Permit to construct alter,impri demolish,or repair any aurelure
'za prior m its issuance.also cequima the applicant far such permit m file A signed sutemem
G that he is licensed pursuant to the pmvislonsofMeCommcror]License Law(Chaptv9 Sq.F[. Floor Area Valuation
(commencing with Section]000)ofDivision3aflhc Businessand ProfsaionaCodil $2500
Nat he Is exempt Nemfmm And the basis for Ne alleged exemption.Any violation of
Section 1031.5 by arty applicant for permit subjects Ne Applkml m a civil funnily of Number Occupancy Type
not mere Nan five hundred dollars($500). 3591102
V
I,Asowwrofthepmpcny.mmyemploymwithwa nOeirmleeompenadon,
will do Ne work and the structure is nm inrendcd lir.Raced for.1.(Sce.1044,8urircss Required Inspections
and PmfeA rms Cote:The Contractor's License law does rot apply m An awns.f q p
property who buildsorimprom thereon,and who dnessuch work himselforshrough his _
own employees,provided Nm such Improvements lie not intended oroRemd!main,If.
however,Ne Wilding or improvement issold within one year of completion,Ne ower-
builder will have Ne burden of proving Nat he did Out build or improve for puryus of
ale.).
zrl.as owner M IW ».Property am allusively contracting with p . -d cenuAaem m
Irvct the project Ism.70A4.Business And Professions Cade:)The Conuxmts U.
cense law dos sot Apply in an owner of property who Wilds or improves tWtem.anl
who contracts for such projects wish A centra tot(s)licensed promoaM in she Comrwamfa
License taw.
❑I Am sxemPtandsS, .B A,P C I.this;teasoo
er Date
W0 P P`ENSATION DECLARATION "
1 hereby affiAm ander f<IWIY of perjury one of the f.lbwing decluutiasc
❑Ihave4ndwillmdnWnACe riiamof Co=ntmulf-insumWWgtr sComped
ation,as provided far by Section 3100 of the Labor Code.fm Ne pert..of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Ia surance,As squired by section
3100 of Ne Labor Code,for the performance of the work for which this permit is issued. '
My Workers Compensation Insurance arricr And Policy number Art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed lithe Permit is forane hundred doBars,3I00)
or loss.)
1 car i(y that in the performance of the work for which this permit is issued.I shall nos
employ any person in any mannymapm become mbjec,j to eWorkers'Conpewtim
Laws of California.Date
Applicant h
NOTICE TO APPLICANT:It. net makinggl a Ceniricam of Exemption,you should
become subject to the Workers Compensation previsions of Ne Labor Code,you mum
.Jz forthwith comply with such previsions or this Permit&hall W dccmedawked. +
z C CONSI'RUCf1ON LENDING AGENCY
(-. I hereby AlGrm that ft.is•cmrsvuctlnn lending Agency for de peffarmanco of
a> de work fur which this permit is issued(Sec.31191,Civ.C.) _
W A IarOmea Name
z Landers Address
U 0 1 cenify that I have road this application and sate Nal the above information is
W corm.I agree m comply with all city and county ordinances and sato laws slating he
0U building construction,and hereby authosne mpreaenmtives of this City to enter upon Bw
Nw ahovc-mcinmed pmpcny(Or inrpccdon....does.
01 (We)agrce to arc,indemnify and keep harmless the City of Cupertino against
rA liabilidesjudgments.costs and expenses which may in anyway amus against add City
U z in consequence of the granting of Nu permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR[ R!:TATI NS 0'
Stgnat ofAapoC�6
9 / LPr• Re-roofs/ d
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she appliam w future bollding mapantsmrc or Iundle haurdom mamrid
as defined by de Cupcnino Municipal Code.Chapter 9.13,and she Health and Safely
retie.section y5533(a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yin ]d9a
Will the applicant or future Wilding Occupant use equipment or device whim If a roof is installed without firs[obtaining an inspection,I agree to remove
civil,herardmn air contaminants as dcfrcd by the Bay Arta Air Crudity Mwugcmmil all new materials for inspection.
District?
❑Yea �gnV
1 have mad Ne hararNwsmateriais requirements un@r Chapter 6.95 of die Califon
nix Health a SAfctyCode,Seedun125515,25533 And M534.1 undcrsmed dwtJthe Wilting
Java nm curensly ha a m gilt shat h is my rt>ponsihility m nosily de mcupmt of Ue
mquimmc when u,t netPt; rmia.ana.r.cw1camof0catrpat ( � SignatureofApplicant Date
/ L O
Owner.raama dasdni Dam All roof coverings to be Class"B"or better
• CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35911021 . 00
DATE ISSUED. . . . . . . : 02/29/2008
RECEIPT #. . . . . . . . . : BS000004057
REFERENCE ID # . . . : 08020192
SITE ADDRESS . . . . . : 20619 SHELLY DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO'
IMPACT AREA . . . . . . .
OWNER HO JEAN C AND GILBERT D
ADDRESS . . . . . . . . . . : 20619 SHELLY DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2923
RECEIVED FROM . . . . : MR HUNG CHEN
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
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 2, 500. 00 0.50 0. 00 0. 50 0. 00
1ELECINSP HOUR 1. 00 122 .38 0. 00 122 .38 0. 00
lEPERMITFE FLAT RATE 1. 00 40 .79 0. 00 40 .79 0. 00
1TRAVDOC FLAT RATE 1 . 00 40.79 0. 00 40.79 0 . 00
---------- ---------- ----------- ----------
TOTAL PERMIT 204 .46 0. 00 204 .46 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------------- --------------- --------------------
CHECK 204 .46 #111
---------------
TOTAL RECEIPT 204 .46
•
D�aa o/ 9a
CITY OF CUPERTINO
• CUPEI'TIN0 GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date: .� 2 J 0 �S
Building Address:: C/
Di? e. �c ��;Frr ,✓ v
Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: �LZL, Phone: _V`3 C 7 — ? 66-1
JC %-�- S f� N TA C� Fax:
Contractor License#: S y 73 S
Cupertino Business License#:
• Contact: / ) Phone: j
Fax:
Residential Commercial ❑
7
Job Description: RQp c, C,1- Q.n4'-st%"+5'. (Or-) 4Inrs
PONXC,, l w', (4 a a&;,) :20C /. AV S(QC(.ARZ P
SGzf040 /,1-10 v c ,rca; t �.�vt.Q
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
I FR, 11FR ❑ 11, 111, V-1HR ❑ 11, 111, lV V-N —
Valuation: Square Footage:
Project Size: Standard �rge ❑ Major ❑
•
CITY OF CUPERTINO
CUPEI,TINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BTEMPPER Temporary Building Permit (good for B
30 days)
1BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h 29.3kw
IBBOILER2 Installation /relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ca
absorption sys over 500,000 Btu/h to •
& incl 1,000,000 Btu/h
1BBOILER4 Installation/relocation of ea M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
/ IELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P •
er hour
1MEETINGIHR Application Meeting B
CITY OF CUPERTINO
• CUPERTINO GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
1ACOUSFDW SFDWL/DuplexNew B
IACOUSRESAD SFDWL/Duplex-Addition/Alteration B
IACOUSCOM Multi-Family/Commercial B
CHIMNEY'S
1 CHIMNEY Chimney B
1CHIMNEYR Chimney Repair B
FENCES
1FENCE>6FT Non-masonry, over 6 ft in height B
1FENCEMAS>6 Masonry, over 6 ft in height B
FIREPLACES
1FIREPLMAS Fireplace Masonry B
1FIREPLFAB Fireplace Pre-Fabricated/Metal B
1FLAGPOL>20 Flag pole(over 20 ft in height) B
1MODUSTRU Modular Structures B
FOUNDATIONS
1FOUNDREP Foundation Repair B
1 PILECAST Pile Foundation Cast in place concrete B
1PILEDRIV Pile Foundation Driven (steel, pre- B
stressed concrete
3 of 5
CITY OF CUPERTINO
CUPE(r;TINO GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
RETAINING
WALUCONCRETE
OR MASONRY
1RETSTN Standard (up to 50 ft) B
1RETSP310 Special Design, 3-10' high (up to 50 `) B
1RETSP10 Special Design, over 10' high (up to B
50'
1RETCRB< Gravity/Crib Wall, 0-10'high (up to B
50 ft
1RETCRB> Gravity/Crib Wall over 10' high (up to B
50 ft
SIDING
1 SIDESTBK Siding, Stone &Brick Veneer B •
interior/exterior
1SIDEOTHER Siding all other B
SKYLIGHTS
1 SKYL<10 SF Skylight less than 10 sf B
1 SKYL>10SF Skylight greater than 10 sf or B
structural
1STAIRS Stairs-first flight/ea addt'1 B
STORAGE RACKS
1 SRACKS<=8 Storage Racks 0-8' high (up to 100 so B
1 SRACKS>8 Storage Racks over 8' high (up to 100 B
st
1STUCOAP Stucco Applications (up to 400 so B
additional stucco application
•
4of5
ZCITY OF CUPERTINO
• CUPEf� TINO GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 WINREP Replacement windows/sliding glass B
door ea 8 windows)
IWINMEWSTR New Window-structural shear B
wall/masonry includes plan ck fee
IEPERMITFEE Electrical Permit Fee E
/ 1 MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMPLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1BSEISMICR Seismic Residential B
1BSEISMICO ' Seismic Commercial B
1TRAVDOC Travel &Documentation B
1BUSLIC Business License B
•
5 of 5
Community Development
It
., *t COpO0 Torre Avenue
rtinoCA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
SCUPERTINO
Building Department
JOB ADDRESS: S /L C Y• PERMIT #
p2o ( � 2
OWNER'S NAME: C—/Ir/l/ 14 PHONE # O l S/O
GENERAL CONTRACTOR: C- S /J'— FAX #
I am not using any subcontractors: t!
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
• Tile
Own /Contractor Signature Date