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12010018 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10535 MERRIMAN RD CONTRACTOR:' PERMIT NO: 12010018 OWNER'S NAME: CHERN GEENG-CHUAN �� DATE ISSUED:01/03/2012 OVI VER'S PHONE: 4086494537 (! PHONE NO: Q. LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# _ MECH RESIDENTIAL COMMERCIAL� Contractor rlr.2k4VA Date v + L_ I hereby affirm that I am ensed under the provisio s of Chapter 9 JOB DESCRIPTION:INSTALL PROPERTY LINE CLEAN OUT (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I 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:$1200 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:34216053.00 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 T 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 DA I UANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS F S INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulati r e Cupertino Municipal Code,Section 9.18. Is~y:y: Date —Signature I OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I 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(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 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 I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 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 25505,25533,and 25534. I 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(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I 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 or authorized agent: become subject to the Worker's Compensation provisions of the Labor Code,I must 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"ork's I certify that I 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, C, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION E ig of this permit.Additionally,the applicant understands and will comply wan all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY ## 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34216053 . 00 DATE ISSUED. . . . . . . : 01/03/2012 RECEIPT #. . . . . . . . . BS000015653 REFERENCE ID # . . . : 12010018 SITE ADDRESS . . . . . : 10535 MERRIMAN RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHERN GEENG-CHUAN ADDRESS . . . . . . . . . . : 10535 MERRIMAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3921 RECEIVED FROM . . . . : 24HR ALOHA PLUMBING 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 1,200 .00 1.00 0 . 00 1 .00 0. 00 1BSEISMICR VALUATION 1,200 .00 0 .50 0 . 00 0 .50 0 . 00 1PPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0: 00 1PRSEWER UNITS 1. 00 22 . 00 0. 00 22 . 00 0. 00 1TRAVDOC FLAT RATE 1.00 44 . 00 0. 00 44 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 152.50 0 . 00 152 .50 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 La (408)777-3228• FAX(408)777-3333• building(cDcupertino.org MISC CUPERTINO /PLUMBING ❑MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS �) <� 3 / _'e r I{� APN# L r' �S OWNER NAMEr V 1 E-MAIL C l��,e �p'�'- M'l'le r h � � n SIR=ADDRESS / V. S `7 J ��e-K-{—/m g l� 44y, ATE,ZIP C U _ C�i' �✓�L� C,1 FAX CONTACT NAME � )_ L� /C I PHONE / Z I tel,} E MAM STREET ADDRESS yl �-(I V(J CITY,STATE, ZIP /t'1 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME/ Y I K( k6 LICENSE NUMBER (� v J LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS1 �i CITY Ci TE �' 0 C1 Y `7\�O r` PHONE 0 7 O 017 ARCHITECTIENGINEER NAME LICENSE NUMBER J BUS.LIC# COMPANY NAME' E-MAM FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WII DLAND ❑��8 PROTECT IN ❑ IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA L� 0 FLOOD ZONE NO EICHLER HOME? ❑NO DESCRIPTION OF WORK r -�r o J TOTAL VALUATION: ` RECEIVED BY: By my signature below,I certify to each of the following:,1_aa�tI}�prop owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is c ct.,j h d e Desc'bion of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin stoic' autho' e r tatives of Cupertino to enter the abov7tified p perry for inspection pu{poses. Signature of Applicant/Agent: ��`" Date:SUPPLEMENTAL INFORMATION REQUIRED OFFICE E ONLY lit_oVER_THE-COUNTER ❑ EXPRESS Y U ❑ STANDARD U ❑ LARGE L ❑ MAJOR MEPMscApp_2011.doc revised 06121111 lot '%Tivi CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION �lADDRESS: 10535 meriman rd. DATE: 01/03/2012 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$1,200 R'PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 RPSS USE: -T-p PERMIT TYPE: WORK install property line clean out SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1 PRSEWER 1 # $22 TOTALS: $22.00 T7Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: 1PPERMIT I Other Plumb Insp. 0.0 hrs $44.00 - 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 prelindina information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (lee Resolution 11-053 L f '-1.-'111 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.001 1 SUBTOTALS: $152.50 $0.00 TOTAL FEE.- F $152.50 Revised: 12/04/2011