12040098 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 736 MILLER AVE CONTRACTOR:TJIP_ PERRIIT NO: 12040098
OWNER'S NAIVE: MOO POK LEE t DATE ISSUED:04/172012
OWNER'S PHONE: 4083181531 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class_ Lic.4 _ 0-`.
/�/ f�1� ' ! C-)
- Z MECH r RESIDENTIAL r COMMERCIAL r
Commetor( ( ` t S Date �-t ((.2-
1
_
1 hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TO CLEAR CODE ENFORCEMENT CASE-CONVERT
(commencing with Section 7000)of Division 3 of the Business&Professions HABITABLE
Code and that my license is in full force and effect. SPACE BACK TO GARAGE:
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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.FI Floor Area: Valualion:$0
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:37542009.00 Occupancy Type:
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
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source gulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.mrc
SignaDme �1� Issued by:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material beng installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,1 agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sce.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three ALI,ROOF COVERINGSTO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIA1 S DISCLOSURE.
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code.Section 25532(a)should 1 store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,1 Health&So Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. d agent:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and slate that the above information is
correct. I agree to comply with all city and county ordinances and stale laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against Iiabilities,judgmenls,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub.: Blk: Lot:
APN . . . . . . . . : 37542009. 00
DATE ISSUED. . . . . . . : 04/17/2012
RECEIPT #. . . . . . . . . : BS000016567
REFERENCE ID # . . . : 12040098
SITE ADDRESS . . . . . : 736 MILLER AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : M0O POK LEE
ADDRESS . . . . . . : . . . : 736 MILLER AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CAL BUILDERS
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
---------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 0.00 1. 00 0. 00 1 .00 0.00
1BSEISMICR VALUATION 0. 00 0. 50 0. 00 0 .50 0. 00
1STINSP UNITS 1.00 130. 00 0. 00 130 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 131. 50 0. 00 131 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 131.50
---------------
TOTAL RECEIPT 131 . 50
Building Department
City Of Cupertino
10300 Torre Avenue
Cu�ertin0t Cfl 9SV�`�'�ZS�
CUPERTtNo
Fax: 409-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOQADDRESS: PERMIT#
OWNER'S NAME: C) PHONE # _
GENERAL CONTRACTOR: BUSINESS LICENSE #
ADDRESS: 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 SUBC TRACTORS HAVE OBTAINED A CITY OF CUP ,,RTINO
BUSINESS LICENSE.
I am not using any subcontractors: « ti
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
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 736 MILLER AVE DATE: 04/17/2012 REVIEWED BY: SYLVIA
APN: BP#: 'VALUATION: $0
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION In en
USE: PERMIT TYPE: v I
WORK To Clear Code Enforcement Case-convert habitable space back to garage
SCOPE
.Llvelr. l'fnn Char'k Plumh. Pion Check Clec. Plan Owck
dlrch_ !'.omit Fre: Plumb. PC,tnic Pee: !Slee. Permit Fee:
Orhar.1/c•ch. In vp. Ocher Plumb Insp. Li I Other Elec. ln.sp.
1 "':(h. In.gx Fcc: Plumb. hnp. Fra• tiler. hasp. Fre:
NOTE: This estimate does not include fees due to other Departments(ie.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prellmina information available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Pee Resohaion 11-053 Ell: 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: Q Reg. Q OTT-5 Thrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? Q Yes 0 No $0.00
Suppl. Insp. Feel@ Reg. Q OT 0,0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Cmrslrnrrion Tax.
.I.hninisf r live Pia': O
Work Without Permit? O Yes 0 No $0.00 E)
Advanced Planning Fee: $0.00 0 hours Inspections O
Traval 0oc-11mvnlalinrl Feer. $130.00 PEEP Inspection, Hourly 0A
Strong Motion Fee: $0.00 Select an Administrative Item
Bld,Stds Commission Fee: $0.00
SUBTOTALS: $0.00 $130.00 TOTAL FEE: $130.00
Revised: 04/01/2012
J CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING OMSION
10300 TORRE AVENUE•CUPERTINO,CA 950143255
CUPERTINO (408)777-3228• FAX(408)T77-3333• building(dcuoertno oro
❑NEW CONSTRUCl10N ❑ ADDITION
ALTERATION Y TI 11REVISION 1 DEFERRED ORIGINAL PERbIIT q
PROlECr ADDRESS �/ AFNI -If 2 -
-��
OWNER NAME ll. 0.� FHT ` ( E.�Anl
SIRFfl'ADDRESS Qrr . Fax
\ VC/ O O
CONTACT NAME E-NFAIL
' STAEEI'ADOBE55 CtiYII__ST''AT$ IIP - q� p
rJ r l A �/ V� ( l
11owNER 13OWNER-BUILDER. 13 OWNER AGENT L7 t.�NmacmR ❑CONTRACTOR AGENT ❑ Axcm= ❑wcooER ❑ oFvaoPEt ❑TENANT
CONIRACTORNAME' . C LICENSE @ LICEigTYPE BUS.LIC#
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COMPANYNAME cck ( ]] \t E MAR
`6
STREET ADDRESS �j ply fATE, A P}fONE
l 0. p'C"( L'C.• -1
ARCHITECDENGI4EEt NAME LICENSE NUMBER Bus.LIC R
COMPANY NAME E-MAIL FAX
STREET ADDRESS ^ CITY.STATE ZIP PHONE
DESCRIPTION OF WORK ' )�^ ro t \Q/� �C�II LfW�'1 �'t l�••�'Y I
EQSWG USE PROPOSED USE CONSTILTYPS SMRiF5
USE. TYPE OCC SQFT. VALUATION(5)
NEWFLOOR OEM TOTAL
AREA A
-^ ^
EXIS AREA AREA TOTAL r' 41 C
aATBx00M KMX3M't ODER
REMODELAAEA REMODELAREA RFMODELARFA
FORCHAREA I DEatA TOTAL DECoeORCH AREA I oARAGEAREAo;%A
ATTAQr
a DWELLING UNTIE: L4ASECONDOMr YES 5RCONDSTORY YES
BKIYGADD®T ONO ADDITIONT NO
PRE-APPLIUTION ❑YES PLANS,NG APPROVAL
OF. OTERBLDGAN [3 YES RECEIVED BY: TOTAL VALU :
PLANNDlG APPLO ❑NO PLANNING APPROVAL L.EI'rEt EICEIFR HOafBr [I NO
/�(_(�f
By pry sigaature belaW,I certify M each of the fallawmg: I am the Property owner ar authorized event to act ao the prppertyr waer's b-half."I have read this
application and the mfo®aCoa I have provided is cfirrem I have read the Description of Work and verify it is accurate. I agree w comply with an applicable local
ordinances and state laws relating to buildin on. I authori=rePmCat uvea of Cupertino to cater the abovee-ide/��e/d Prop/qry, far m' spxtioa pm-poses.
Signa tme of APplic2nt7Ageae .. Date. l l 1 lr1
SCiPPLEbfEIYC 0 TION REQLMU D PLAN SCK TYZL Rol=G Sts
New SFD or Multifamily dwellings: Apply for demolition permit for 0 -TEz-ComrrxR iH—G PLAN E VEEW
eustiag building(s). Demolition permit is required prior to issuance of building
permit for new budding. ❑ KBPRMS ❑ PLANNING PLAN REVIZW
-Commercial ComerciaMa
l Bldgs: Provide a completed Hazardous Materials Disclosure C1STANDARD ❑ PUBLIC WOREs
form if any Hazardous Materials are being used as part of this project ❑ LARGE 0 M bEP[
Copy of Plamliag Approval Letter ar Meeting with Planting prior to '
Submittal ofB Permit ❑ MAJOR ❑ SANTIARYn-MMOMTRICT
urldmg applicatioD.
❑ MWIROMNENTAL HEALTa.
BldgApp_2011.doc revised 06/21/7/