09070140 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �S�� tl I�t`� MTINfi
BUILDING ADDRESS: PERMIT NO.
10421 CORTE DR MADRID YOUR. RT74HT
OWNER'S NAME: PERMIT ISSUE DATE
Qp;ij 649N E)R 86
.o A CONTROL NO.
408) 981-2878
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o pLICENSED CONTRACTOR'S DECLARATION
mE I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z W with Section 7000)of Division 3 of the Business and Professions Code.and my license is
yin full force and effect UPGRD E LECTRCL PANL FOR HOME FM 10 DAMP TO AT
Cz License Class Lie.0
-,0° Date Contractor LEAST
ARCHrfEc'rS DECLARATION
a< I understand my plans shall be used as public records 2 0 DAMP
DyU
C
E4 Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
C O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
R3 which requires a permit to construct,alter.improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
E=O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 1 O 0 0
y .. 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 APN Number Occupancy Type
not more than five hundred dollars($500). 37505002 . 01
❑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,Business
and Professions Code:The Contractor's 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.).
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U-
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 der Sec .B&P Cfor this Masons
Owner 6� Cf
� Date V r Q 1
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for 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 Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. 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 1p c subject to the Workers'Compensation
Laws of califo • D �_
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z R CONSTRUCTION LENDING AGENCY
f~t 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.)
WCC,0 Lender's Name
L
Z cmices Address
V C) 1 certify that I have read this application and state that the above information is
LL►" corccL I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
U
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
r-- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: p�
SO__U�AF9E� R�ggULATTONS.
5� 011901 d Re-roofs
Signature'&Applicant/Contractor are
HAZARDOUS MATERIALS DISCLOSURE Type Of R oof
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(a)? 1 All roofs:;hall be inspected prior to any roofing material being installed.
❑Yes p()No
Will the applicant or future building occupant use equipment or devices which If a roof is 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 In 3terials for inspection.
District?
C3 Yes 4JNo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if thc building
docs not currently have a tenant.that it is my responsibility to notify the occupant of the
requi nnis whi h must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
�f^" P9 0Z12,01-0`1 All roof coverings to be Class in"or better
Owner or authorized agent Dare
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT' RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: B1}:: Lot :
APN . . . . . . . . : 37EI05002 . 01
DATE ISSUED. . . . . . . : 07/20/2009
RECEIPT #. . . . . . . . . : BS000008226
REFERENCE ID # . . . : 09070140
SITE ADDRESS . . . . . : 104:21 CORTE DE MADRID
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . EVIL & AMY LEE
ADDRESS . . . . . . . . . . : 104:21 CORTE DE MADRID
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : EVIL & AMY LEE
CONTRACTOR . . . . . . . : LAI. SHUI MICHAEL LAU LIC # 29888
COMPANY . . . . . . . . . . : YOUR RIGHT CHOICE
ADDRESS . . . . . . . . . . : 35" DAWSON DR
CITY/STATE/ZIP . . . : SAITA CLARA, CA 95051
TELEPHONE . . . . . . . . : (408) 981-2878
FEE ID UNIT QUANTITY INOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
1BCBSC VALUATION 1, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1ERT<200 UNITS 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 127 .50 0 . 00 127 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 127.50
---------------
TOTAL RECEIPT 127. 50
af CITY OF C_.UPERTINO
CITY Of
CUPEI�TINO GENERAIJ BUILDING
PERMIT APPLICATION FORM
APN# D U� �/'�� Date:
D-71 15l D q
Building Address:
Io4.21 Gorse ae Madrid, Gu Him. CA 15oik
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of 's project? Yes No
HOA: Exterior work only) Yes E] No If es, rovide letter from HOA
Owner's Name: Phone#:
Evc, � AMy Lee 130%.319(. 12605
Contractor: (C L your IZ1 9M GhoiGe Phone-
Fax:
haone-
Contractor License#: 83(po t�
Cupertino Business License#: 8 �
Contact: Phone:
Fax:
Residential Commercial
Job Description:
Upgrade a(ec.T� cul pa�n�( �r Inonne Frons (UOf �iv at (e�is} )C�f� ��
Building Permit Info:
Bldg ❑ Elect 9 Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
S�nyle- f atrn►ly
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-13 ❑
Valuation: Square Footage:
:A k K)o) c. 122( sy,, W
Project Size: Express tandard ❑ Large (] major ❑
Green Building: Please complete relevant portion A the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: 6L—
For help, contact Build it Green at www.builditgmen.or
Revised 07/14/09
CITY OF C.UPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPERTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additiona: stucco application
1 WINREP Replacers.ent windows/sliding glass B
door (ea 3 windows)
IWINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
f 1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
IPPERMITFEE Plumbing Permit Fee P
I ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
IBSEISMICR Seismic F:esidential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
IBUSLIC Business License B
5 of 5
Community Development
N 10300 Torre Avenue
;'yam', Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
.-UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
10 2 Corte, de Madrid, Cu trVI"o, CA 15014 eat/t--tC�
OWNER'S NAME: 9VG4 k Amy Irk PHONE #
GENERAL CONTRACTOR: Your Lpj(z FAX #
I am not using any subcontractors: .sk -�y bZ 1,1-O("
Signature Date
Please check applicable subcontractors and com-Aete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date