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11110004 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22791 MEDINA LN CONTRACTOR:BELL CONSTRUCTION PERMIT NO: 11110004 OWNER'S NAME: LU CHI-LAN TRUSTEE&ET AL 1373 RAMON DR DATE ISSUED: 11/01/2011 'ER'S PHONE: 4086793673 SUNNYVALE,CA 94087 PHONE NO:(408)202-8370 LICENSED CONTRACTOR'''S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class E Lic.p 63vt)0 MECHr RESIDENTIAL COMMERCIAL r Contractor P41 66MS frUCf_10 Date U& 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APT B-REPLACE 50 SQFT OF SIDING AT FRONT OF (commencing with Section 7000)of Division 3 of the Business&Professions HOUSE WITH WINDOW TRIM Code and that my license is In full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: 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 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$700 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:34230009.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accme against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9'18. /^��^ �, �� Issued by: g � Vim'' Si nature _ I/r Date • _OWNER-BUILDER DECLARATION RE-ROOFS; All roofs shall be inspected prior to any roofing material berg installed.If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,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(See.7044, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the prgject(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 I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 255059 25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner oraVlhorized mm nt: become subject to the Worker's Compensation provisions of the Labor Code,1 must a AID am Date: forthwith comply with such provisions or this permit shall be deemed revoked, CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that 1 have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address ondcnify and keep hamtless the Ciry of Cupertino against liabilities judgments, and expenses which may accme against said City m consequence of the ARCHITECT'S DECLARATION � ng of this permit.Additionally,the applicant understands and will comply ll non-point source regular,,,,per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Dare • CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34230009. 00 DATE ISSUED. . . . . . . : 11/01/2011 RECEIPT #. . . . . . . . . : BS000015204 REFERENCE ID # . . . : 11110004 SITE ADDRESS . . . . . : 22791 MEDINA LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO . IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : LU CHI-LAN TRUSTEE & ET AL ADDRESS . . . . . . . . . . : 22791 MEDINA LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BELL CONSTRUCTION CONTRACTOR . . . . . . . : JONG NAM KIM LIC # 28151 COMPANY . . . . . . . . . . : BELL CONSTRUCTION ADDRESS . . . . . . . . . . : 1373 RAMON DR CITY/STATE/ZIP . . . : SUNNYVALE, CA 94087 TELEPHONE . . . . . . . . : (408) 202-8370 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ----—---- ---------- ---------- ---------- ---------- 1BCBSC VALUATION . 700 . 00 2 . 00 0 . 00 2 . 00 0. 00 1BSEISMICR VALUATION 700 .00 1.00 0. 00 1 .00 0. 00 1SIDEOTHER SQ FEET 50 .00 784 .00 0. 00 784 .00 0 .00 1TRAVDOC FLAT RATE 1 .00 88.00 0.00 - 88 .00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 875. 00 0. 00 875.00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 875 . 00 VISA --------------- TOTAL RECEIPT 875 .00 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 •GUPERTINO (408)777-3228• FAX(408)777-3333 • buildina(rDcuoerdno ora ❑NEW CONSTRUCTION ❑ ADDITION )9ALTERATION/T1 ❑ REVISION/DEFERRM/� O RIGINALPE PmI T N PROJECT ADDRESS all ( ILieAPNOp / 50 Uv OWNERNAME CH II — G—` rV ' l tiPHONE � 6� f_361S E-MAIL STREET ADDRESS MtII"KA Lw� CITY. STATE.ZIP /LkMv ^ FAX CONTACT NAME /)A) ` --Z PHONE E-MA) STREET ADDRESS ,}.// CITY,STATE, ZIP FAX ❑OWNER C1OWHER-BUILDER 13OWNERAGENT ate C1NTMCOR ❑CONTRACrORAGENT ❑ ARCHn ECT ❑ENGINEER ❑ DEVELOPER ❑ TENAM CONTRACTOR NAME C, 1� //-/ M1A LI RENUMBER 63 6 LICENSE TYPO Q BUS.LICA COMPANY NAME I(�,n (I /v/' u(�,.�L/1 vBl E-MAIL V FAX . STREET ADDRESS `I-/3G1/l3 P(C�Mon Dr CITY.STATS,ZIP h n �a j n. CA /�� PHONE 1�Q 3 —6C O/ ARCHTTEC/ENGINEER NAME LICENSE NUMBER G N'7 Y"' BUS.LIC pT V(J l! u"tTD COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE tESCRIMMON OF WORK /' Ce I,I&rl�TING USE PROPOSED USE CONSTRTYPE pSTORIESuSE TYPE GCC. SQ.FT. VAJ-UATION(s) TG NEW FLOOR - DEMO TOTAL AREA AREA AREA NET AREA O+ 0 i l BATHROOM KITCHEN OTHER C/ REMODELAREA REMODEL AREA REMODELAREA PORCH MEA DECK AREA TOTALDECK/PORCHAREA GARAGE AREA DETACH ATTACH p DWELLING UNM: ISASECONDUM YES SECONDSTORY YES BEING ADDED? []NO ADDITION' [3NO PAP-APPLICATION AYES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECENID TOIL.VALUATION: PLANNNGAPPL# [3NO PLANNDJG APPROVAL LETrER EICMERHOME? []NO ,`/l,VA `ATIO By my signature below,I certify to each of the following: I am the property owner or authorized a¢ent t t the prpperty owner's behalf. I have read this application and the information I have provided is cornet I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I uthorize representatives of Cupertino to enter the above-ides'Sed property for inspection purposes. Signature of ApplicanUAgent: Date: SUPPLEMENTAL INF TION REQUIRED PLANCAECKTYPE ROUTING SLEP _New SFD or Multifamily dwellings: Apply for demolition permit for ovER-Tm,cotJNTnst ❑ BUDDING PLAN REVEEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANMG PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ cAacz ❑ trmE nJST Copy of Planning Approval Letter or Meeting with Planning prior to C1 MAJOR ❑ SANITARY SEWER DtsTRtcr bunittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH. B/dgApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22791 Medina Ln. DATE: 11/01/2011 REVIEWED BY: gs APN: BP#: "VALUATION: $700 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex Pup1GENRES USE: PERMIT TYPE: WORK I Re lace 50 s ft of siding at front of house with window trim. SCOPE C/wok Phw,t . Plan Che(A Elec,Plan ChCCIP :Rech. P urmil Gee: PlanrL.Permir Gr.�c' J3;r.. Perndr re(,. Other rlfech.Insp. ONter Plumb bup. Qr,'rar Fier.. ]n��p. ED M,, Lh Incp. Fee: Mmn6. In'[), P:ler.lnvp. Fee. NOTE: This estimate does not Include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District eta). These fees are based on the prellidna to ornnation available and are only an estimate. Contact the Dept for addn'l infa FEE ITEMS /fee Resolution 11-053 Elf 7/li/U FEE QTY/FEE I MISC ITEMS Plan Check Fee: $0.00 = s.f. Siding Suppl. PC Fee: (F) Reg. Q OT 0.0 hrs $0.00 $392.00 ISIDEOTHER I All Other PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. ©OT I 0,0 I firs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 {,onstruction my .Administrative Fee O Work Without Permit? © Yes 0 No $0.00 1 E) Advanced Plannint Fee: $0.00 Select Non-Residential 0 7;uvel Dncarrneniurinr Fees: Building or Structure O Strong Motion Fee: IBSEISMCR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $392.00 TOTAL FEE: $393.50 Revised: 10/01/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 U P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: F -A fn I PERMIT# I I I i OWNER'S NAME: - l_,4 N L. aLA IPHONE# � 0 GENERAL CONTRACTOR: C BUSINESS LICENSE# I S- ADDRESS: IMI Eamoy\ CITY/ZIPCODE: n *Our municipal code requires all businesses working in the city to have a City of Cupertino 6usiness 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 Roofi ng Septic Tank Sheet Metal Sheet Rock Tile Owne /Contractor Signature Date