11110143 (2) CITY OF CU1,!URTIN0 BUILDING PERMIT
BUILDING ADDRESS: 11800 UPLAND WAY CONTRACTOR:MR.RESCUE PLUMBING PERMIT NO: 11110143
&ROOTER
OWNER'SNAME: BENJAMINLEE 4231 BUSINESS CENTER DR STE 12 DATE ISSUED: 11232011
NER'S PHONE: 408 FREMONT,CA 94538 PHONE NO:(877)417-3728
I /❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class C-3(:f) Lic.4 I PROPERTY LINE CLEAN OUT
ContractorDate
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
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. Sq.Ft Floor Area: Valuation:$2000
1 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 APN Number:36603016.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property far inspection purposes. (We)agree to save 180 DAYS Q LAST CALLED INSPECTI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: V Date:
with all non-pointsourc5pg1r9m"lheCAtpt ino Municipal Code,Section
9.18.
__ _ RE-ROOFS:
ISignature.---- —'Dat / All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for one of Signature of Appiimt: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole comfensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,'
Business&Professions Code)
I,as owner of the property,am exclusvely contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25pr
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: –Date:
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of Cal ifomia. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 relafing
to building construction,and hereby authorize representatives of this city to enter
WWandabove mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
nify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
Building Department
i. . _.
City Of Cupertino
p GD� 10300 Torre Avenue Cupertino, : 4 8-777-3229
Telephone: 408-777-3228
.0 U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: fm[) PERMIT#
OWNER'SNAME: 'j aJZ PHONE#
GENERAL CONTRACTOR: r+ BUSINESS LICENSE#
ADDRESS: y231 wgi yv C �r CITY/ZIPCODE:
*Our municipal code requires all businesses working 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 SUBCONT ORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. _
1 am not using any subcontractors:
Signatu?efollowing
Date
Please check applicable subcontractors and complete t information:
t/ 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 C)-Z)1 L,IO
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contrac r Signature Date
• CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36603016.00
DATE ISSUED. . . . . . . : 11/23/2011
RECEIPT #. . . . . . . . . : ES000015402
REFERENCE ID # . . . : 11110143
SITE ADDRESS . . . . . : 11800 UPLAND WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BENJAMIN LEE
ADDRESS . . . . . . . . . . : 11800 UPLAND WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : MR RESCUE
CONTRACTOR . . . . . . . : MIAN AHMED LIC # 31330
COMPANY . . . . . . . . . . : MR. RESCUE PLUMBING & ROOTER
ADDRESS . . . . . . . . . . : 4231 BUSINESS CENTER DR STE 12
CITY/STATE/ZIP . . . : FREMONT, CA 94536
TELEPHONE . . . . . . . . : (877) 417-3728
•
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 2, 000 .00 1.00 0. 00 1. 00 0. 00
1BSEISMICR VALUATION 2, 000.00 0.50 0. 00 0 .50 0. 00
1BUSLIC FLAT RATE 1.00 115. 00 0 . 00 115.00 0. 00
1EPERMITFE FLAT RATE 1 .00 44 . 00 0.00 44 .00 0.00
-ERT<200 UNITS 1.00 44 . 00 0. 00 44 .00 0 .00
1TRAVDOC FLAT RATE 1.00 44 . 00 0 .00 44 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 289.50 0 .00 289 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 289.50 1049
---------------
TOTAL RECEIPT 289.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
•
D
A.
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
• 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 �7
CUPERTI NO (408)777-3228• FAX(408)777-3333•buildinGna cuoertino.ore 1 I ^1
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/1'1 ❑ REVISION/DEFERRED ORIGINAL PERMIT N •/
PROIECIADDRESS
f1/(0JV Ole
rh APN x C) AI) Q
OWNER NAyPHONE E-MAIL
_e t— 1
STREET ADD0.ESS1/p ' CITY�S`TAT ZI �� FAX
CONTACT NAE �� I`^ �iV0 �J PHONE�� -�7y E-MAIL
STREET'ADDRESS Il V CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ oWNERAGFNT ❑ CONTRACTOR ❑CONTRACTORAGEW ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONI'RAC'TOIt NAMG �n 1 _ K ; ` LICENSE NUMBF,9 -31 114 t.ICI ET�YPE- BUS.LLCM
COMPANY NAME F K' r n 0-•+ [-MAI V/ _I 1u FA%
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STREET
STREETAooREss E1 I u6I r�5 CA>}DZ. G"res 'ZIP (,'n "/ `��3 PSiO -2�7 —1 Yat+
AKCHI l'ECTIENGINEER NAME LICENSE NUMBER BUS,LIC M
COMPANY NAME. E-MAIL FAX
SI REE"I'ADDRESS CITY,STATE,ZIP PHONE
• DESCRIPTION OF WORK
EXISTINGUSI! PROPOSED LSE CONSTR,TYPL #STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NETAREA
BATHROOM KITCHEN O"TIIER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECKAREA TOTAL DECK/PORM AREA GARAGEAREAI DL7ACH
ATTACH
M DWELLING UNIT S' IS A SECOND UNIT' E]YES SECONDSTURV ❑YES
OEINGADDEDf, El NO ADDITION! [:]NO
PRI:-APPUCA110N El YES IF'YF.S,PROVIDECOPYOF IS'I'IIEULDGAN ❑YESRECEIVED BY: TOTAL VALUATION:
PLANNING APR.I EJ NO PLANNING APPROVAL LETTER PICHLER NOME? E]NO I r1-O ep' O:Z
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verily it is accurate. I agree to comply with all applicable local
ordinances and slate laws relating to building coiseffI113toT,.I onz representatives ofCupenino to enter the above-identified propyl try for inspection purposes.
Signature of Appl icont/Agenf. Date'
SUPPLEMENTAL INFORMATION REQUIRED ,PLnry cuecK TYPE ROUTING SLIP
_New SPD or Multifamily dwellings: Apply I-or demolition permit for ❑'OVER-TILE-COUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD '❑ PuBLIC WORKS
GIInI if any I11lzardotls Materials are being used as pan of this project.
.❑ LARGE' - I �❑ FIRF.DEPT.. ' r.,
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY BE DISTRICT,
submittal of Building Permit application.
❑ ENVIRONMENTAL HEAUI'll
Bldgdpp_2011.doc revised 06/21111