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09070006 CITY OF CUPERTINO BUILDING DIVISION PERMIT � � � � BUILDING ADDRESS: PERMIT NO. 22330 HOMESTEAD RD APT 209 TBD - TD BE D OWNER'S NAME: PERMIT ISSUE DATE RAO-CHAM., PAI SNE: S A CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u O p LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description v r— Z with Section 7000)of Division 3 of the Business and Professions Coded my license is y in full force and effect. Z REPLC SINK, FAUCT IN KITCHN & BATH TUB, BACKBOARD D M? hip,License Class Lic.$ E-,m Date Contractor & WALL PILE - WYSE PROPERTY SVC PD FOR BUS LIC .r A H DECLARA ON I understand my pi shall be used as public records D d L O H Licensed Professional n y OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the o O following mason.(Section 7031.5,Business and Professions Code:Any city or county .< Pi which requires a permit to construct,alter,improve,demolish,or repair any structure Z prior to its issuance,also requires the applicant for such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation XI-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 4 O O 0 y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(5500)_ 32659999 .209 ❑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 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 We.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 Contractoes 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 OwnerDare WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 7 have and will maintain a Certificate of Consent to self-insure for Workces 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 am: 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 to omc o the Workers'Compensation Laws of California.Date Applicant - NOTICE TO APPLI :If,after makin 1s crtificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. Z ' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a convection lending agency for the performance of (]; the work for which this permit is issued(Sec.3097,Civ.C.) W�,A Lender's Name Z Lender's Address V 0 1 certify that I have read this application and state that the above information is Iy t" correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building convection,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 tF-t to 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 �/ v t"t APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL NON-POINT Issued by: SOURCEREGUL NS. —' ��► �� Re-roofs C7 Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of R sof 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 Cede,Section 25532(a)? All roofs:,hall be inspected prior to any roofing material being installed. ❑Yes �Io Will the applicant or future b ilding occupant use equipment or devices which If a roof i:,installed without first obtaining an inspection,I agree to remove t hazardous air contaminants as Harmed by the Bay Area Air Quality Management all new m iterials for inspection. strict? �W^L,/ ❑Yes u 1 have read the hazardous materials requirements under Chapler 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building r / does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must met prior to•6hance of a ficate of Occu an q P � �"i � Signature �f Applicant ate r All roof coverings to be Class"/ "or better Owner oauthorized agent Dare CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk.: Lot : APN . . . . . . . . : 32E59999 .209 DATE ISSUED. . . . . . . : 07/ 01/2009 RECEIPT # . . . . . . . . . : BSC00008096 REFERENCE ID # . . . : 09C70006 SITE ADDRESS . . . . . : 22_30 HOMESTEAD RD APT 209 SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PAC)-CHANG PAI ADDRESS 22_ 30 HOMESTEAD RD APT 209 CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHFNG F YING CONTRACTOR . . . . . . . : TBI - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBI - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 4, 000 .00 0 . 50 0 . 00 0 . 50 0 . 00 1BUSLIC FLAT RATE 1 .00 114 . 00 0 . 00 114 . 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1PREPPIPE FLAT RATE 2 . 00 84 . 00 0 . 00 84 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 283 . 50 0 . 00 283 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 283 .50 DISCOVER --------------- TOTAL RECEIPT 283 .50 tl _ — r } 1WE - rew Assessor's Parcel Number: Name of owner. — G, ti. S to-,Project address. Contact person. �i(/� PY.one. Fox. .i Net square footage of lot. . Existing Proposed ;- Square footage: First floor: Second floor: Garage: ' 4 TOTAL: `re there at least two 10 foot by 20 foot clear spaces inc;ide the garage. is privacy protection planting required for the project? N On what floor(s) is work being done? /A C Brief desc on of ork. ke,-,k) j<<�.P ,� /f� �� '0,� bAw Code editions:2008 CBC -N)2008 CFC (Y -N)2008 CMC (Y-N) 2008 CPC -N)2008 NEC (Y-N) Effective 1C,!( UkVA t F\N`) OR©INA1 - 16N��" r,� it,is Stns set oVO 0"t r 'ay" +�n IMS- wttt; v _ 3 mP S T IM W01119g of `p i " B f--- MEE She , 0,+ ..'1 P� ;HAV-N 0 the Plan Review Process Work Book Page-8-Revised 1/1/08 v ro 4 [C T&A CAI J&tr.-C, �', ��' iAj 0,() l� 91 N t f�y � �Q _ r _ Z� 1/ � 2� Hyl• -�' - � 4 � ..� .'�ti r�li{�nQ�`i 7 t �n k_�.J�.� (�v T R TY�FT I/r�/ .mow iL 1 Y b� o� v� �o -�tA, �ov �oAy cP� lz Gw I ►,U 09 °7(D(y) 1� CITY OF CUPERTINO IT F CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # 3 0-1(p5 Id Date: Building Address: 2 n dlheiS t°w a� �f. 'It 20 GG � '✓� O OL Mailing Address (if different from building address): Owner's Name: T CI _ . ,?A, )' Phone#: -- HOA: (Exterior work only) Yes ❑ No Q If yes, provide letter from HOA Contractor: Phone: 4(9Q �3 p� C heN Y�� Fax: �/ Contractor License #: y C, Cupertino Business License #: Contact: / Phone: 4 e ? 50!- Fax: 0!- Fax: Residential M Commercial Job Description: e� � ,A/ k �6ujlfcet ►A/ /SC,��d baf4U hark 177&,A. av,/ wall Building Permit Info: Bldg EK' Elect ❑ Plumb 2-11*, Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-13 V Valuation: Square Footage: Project Size: Express Standard ❑ Large [] Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicabic, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.builditgrE en.or Revised 02/05/09 1 CITY OF CUPERTINO C U CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 3 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK 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 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES I BSEISMICR Seismic F.esidential B 1 BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B ' 1 BUSLIC Business License B 5 of 5 Community Development AW 10300 Torre Avenue lf,-70-ma SAA Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 TPEkTINO Building Department JOB ADD"�3-3 O PERMIT # OWNER'S NAME: c� �' PHONE # 3 _ FO GENERAL CONTRACTOR: FAX # I am not using any subcontractors: _ Signature Date Please check applicable subcontractors and com Clete 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date