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07080022
CITY OF CUPERTINO BUILDING DIVISION PERMIT PERMIT NO. BUILDING 4IIf�(2sS:VAI AV CHANG �3ENJAMIN M AND ELLEN 07080022 OWNER'S NAME: PERMIT ISSUE DATE CHANG BENJAMIN M AND ELLEN M 21391 `IAI AVE E: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH z ' LICENSED CONTRACTORS DECLARATION o I hereby affirm that I am licensed under previsions oCChapter 9(commencing Job Description w with Section 7000)of Division3oftheBusinessandProfessionsCode,andmylicenseis ADD ELECTRICAL WIRING SWITCHES, PLUGS, LIGHT SAND ti in full force and effect. z License Class Lic.q NEW SU13 PANEL TO EXISTING STRUCTURE p Date Contractor °j ARCHITECTS DECLARATION a I understand my plans shall be used as public records U H Licensed Professional - OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the Oa following reason.(Section 7031.5,Business and Professions Code:Any city or county ;l which requires a permit to construct,alter,improve,demolish,or repair any structure :11 prior to its issuance,also requires the applicant for such permit to file a signed statement a that he is licensed pursuant to the previsions of the Contractor's License law(Chapter 9 Sq.Ft. Floor Area Valuation o (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1000 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of A Number Occupancy Type not more than five hundred dollars($500)- 36205016 . ❑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.7044,Business and Professions Code:The Conuactoes License Law does not apply to an owner of Required Inspections property who builds or improves thereon,and who does such work himself 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 completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). 19 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon.and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. [-]I am exempt under Sec. ( B&P C for this reason Owner \\._Q t.. C�/L ObtZ Date %2 RK S COMPENSATION D RATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificateof Consent to self-insure Cor Worker's Compen- sation,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 Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant o r— LICANT: NOTICE TO APPIf,after making thhkcrtificalc of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must Q forthwith comply with'such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY V) I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) 7 Q Lender's Nam c z Lender's Address 0 I certify that l,havc 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 Ubuilding construction;and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes. y a (We)agree to save,indemnify and keep harmless the City of Cupertino against In liabilities,judgments,costs and expenses which may in any way accrue against said City Z in consequence of the granting of this permit. ►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date 2- SOURCE REGUL'ATI at Re-roofs Signa urc of Applicant/Contram Date . HAZARDOU MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(x)? All roofs ;hall be inspected prior to any roofing material being installed. ❑Yes . El No Will the applicant or future building occupant use equipment or devices whichIf a roof i.;installed without first obtaining an inspection,I agree to remove emit hazardous.air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes" �No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building docs not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which mel prior to issuance of a Certificate of pan Signature of Applicant Date All roof coverings to be Class"B"or better Owner or authorized agent Date _ �. 0-- t. a �+MY CUPERTINO .� . Assessor's Parcel Number: Name of owner. VIN - - ��, Phone. Contact person. —�— Fax. Net square footage of lot. Ex ProPro Square footage: First floor: Second floor: Garage: ----------- TOTAL: -- Are there at least two 10 foot by 20 foot clear spaces inside the garage? Is privacy protection planting required for the project? On what floor(s) is work being done? (y4s work. Brief description of (( _, Code editions: 2001 CBC (Y - 2001 CF(: N)2001 CMC (Y-N) 2001 CPC (Y-N)2001 NEC 4�57,)-N) ,�XpPRCYVF—E Effective 11/1A0V_C011DANnE WITH THE CITY ��oRn�Nanc�S �:up �tNO CODE s Ar:c 51GNEtJ __n} ;: ;i ticps - This set J• %;I times and rt Is U+ t)e kept r n t;,; „-5 or a'teration iavatul to �, r ,erg t,c;�mrs.,ion i on semi. the bUiia;r 8 t'e. a., h� a vi T ;tris pian;:nU 5pe:,ificat�oi;� CS The stanr MM L mit or to be �r a SHALL NO-1 tie -le to P'" novas+rn jpproval of the v�rta.i�n of anI t- - � Qrd;rlhrlCe �r ~rata i 7..+ ,s anV �rtV Page-B-Revised 8/22/05 Plan Review Process Work Book OWNER-BUILDIIR VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A. All the work authorized by this permit B. — A portion of the work C. — None of the work If or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the wDrk (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s I other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' co npensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed ............................................................................................. I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Date: cr� Property Owner's Signature: �Z – Job Address: 2k3�( Q c. C upP(-fi AJ Permit# Any chances to the information provided c-n this form shall be submitted to the City of Cupertino Build Department. CITY OF CUPERTINO 5 ITEMS OF 5 PERM::T RECEIPT OPERATOR: CathyS COPY # 1 Sec: Twp: Rng: Sub: B_-k: Lot: APN . . . . . . . . . 36205016. 00 DATE ISSUED. . . . . . . : 03/02/2007 RECEIPT #. . . . . . . . . . B:3000002247 REFERENCE ID # . . . : 0'7080022 SITE ADDRESS . . . . . : 2:-391 VAI AV SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : CHANG BENJAMIN M AND ELLEN M ADDRESS . . . . . . . . . . . 2:391 VAI AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4934 RECEIVED FROM . . . . : BIWJAMIN CHANG CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : CHANG BENJAMIN M AND ELLEN M ADDRESS . . . . . . . . . . : 2:-391 VAI AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4934 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- •---------- ---------- ---------- ---------- BENERGY PERMIT FEE 1. 00 34 .86 0. 00 34 . 86 0. 00 BREMFIXT NO. FIXTURES 9. 00 10.80 0. 00 10.80 0. 00 BREMRECEPT NO. OUTLETS 14. 00 16 .80 0. 00 16.80 0. 00 BSEISMICRE VALUATION 1, 000. 00 0.50 0. 00 0.50 0. 00 EPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38.37 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT. : 101.33 0. 00 101 .33 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 101 .33 VS --------------- TOTAL RECEIPT 101 .33 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL CITY OF ��UPERTINO OW OF PERMIT APPLICATION FORM CUPEkTINO -_7J Z-2 APN# � ` t6 � � Date: Building Address: Q13q( Voct ,Ave- Mailing Address (if different from building address): Owner's Name: CJAa n IPhone#: Contractor: ©rt? License #: Contact: Wr�,Y\ 0Aa`^„ Phone: 400 e52,5-7}� Cupertino Business License#: T' Fax: Building Permit Info: Bldg ❑ Elect Ir Plumb ❑ Mech ❑ Job Description: A8C\, plu'S, t�5kits ot i hPw Sa-4 P17nQ &J Residential KI Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: M d;no R�v�I,� ti,,�; r;n� t Please check this box if the project is a �J -SL16 econd-storyaddition: ❑ Project Size: Standard ❑-- Large ❑ M,-jor ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Bailer<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boi.er> 500K to 1 M Btu MECHANICAL BBOILER4 Boilor> 1M to 1.75 M Btu MECHANICAL BBOILER5 F�oiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Cc n. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax —Resi/Mobile BUILDING BELEC 1000 E]ec 600V <= l OOOA ELECTRICAL BELEC1001 Flee 600V> 1000A ELECTRICAL BELEC200 Elea Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD :energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of 3