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12060050 CITY OF CUPERTINO BUILDING PERMIT BUILDINC ADDRESS: 22791 MEDINA LN CONTRACTOR:13111-1.CONSTRUCTION PERMIT NO: 12060050 OWNER'S NAME: YUJING WU 1373 RAMON DR DATE. ISSUED:06/08/2012 OWNER'S PHONE: 2109364817 SUNNYVALE,CA 94087 PHONE NO:(408)202-8370 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALCOMME:RCLAL License Class1-�) / _ Lic.H a b UNIT B- REPLACE 6 WINDOWS AND I PATIO DOOR fQ�, Contractor 'J�I 6Pif;J Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing wfth 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 maimain a certificate of consent to self-insure for Worker's Compensation,as provided Ibr by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Arca: Valuation:$4000 1 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 APN Number:34230009.00 OccupancyType: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize rep mmunives of this city to enter upon the above mentioned property far inspection purposes. (We)agree to save 180 DAY OM LAST CALLED INSPE I N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City inconsequence of the7 C(/ grunting of this pcmhit. Additionally,the applicant understands and will comply Issued by: Z L Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RF:ROOFS: SignatureDate All roofs shall be inspected prior In an) cooling material heing installed II'a roof is D installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BIIILDF.R DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant', Dale: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or mhy employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the properly,,an exclusively contracting with licensed contractors to HA"LARDOUS hIATF.RIAI S DISCLOSURE: construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 695 of the California lleallh&Safety Code.Sections 25505,25533,and 2553.1. 1 will I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the declarations: IIeallh&Safely Code.Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Alanegement District 1 performance of the work for whichihis permit is issued. will maintain compliance wish the CuperfirmMunicipsif Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the lleallh&Safely Code.Sections 25505,25533,and 25534. Section 3700 of the labor Code,for tie performance of the work for which this lig G D Owner or authorized agent:�/ A w Dale: permit is issued I certify that in the performance of the work for which this permit is issued,l shall not employ any person in my manner so as to become subject to the Worker's Compensation laws of Cali forms- If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to die Worker's Compensation provisions of the labor Code.I must I hereby ammh that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this period is issued(Sec.3097.Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.I agree 10 comply with all city and cohmty ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned properly for inspection purposes.(We)agree to save ,ARCIII"1'F.C'1"S DECLARATION indemnify and keep hamlle']1 the 61y of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City inconsequence of the 1 understand my plans shall be used as public records, granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Dale N JUN 0 S 2012 1 -� C-rArrA j a BY:_ l LW .qj DEVEI JPMEM DE MENG DIVI BION-CUPERTINO ziOVED d s t at the Itp 1,$+D X 3—On lob she during construction. It is unlawful to make any LIU 1/� i o om „ changes or alterations on same,or to deviate dd therefrom,without approval from the Building Official. Th ,efamninn of this plan and specifications SHALL NOT I a held to permit or to be an approvalf tl violati n —.0c f any provisions of any City Ordinance ate w. gy .E /✓ 72T / 0 0 Z D? E � '� - 4 o PE iMIT NO. eA ' O Tat- al I 2T r yr r_ P CTl 1® ¢-0 x 3r 0r �1 — 10 OF -0 i� Offx O I on X V—man I>f i >OWFICE COPY G 6 —0 n X U! —D 1/ d 6' x 618 a+r o CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp.: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34230009.00 DATE ISSUED. . . . . . . : 06/08/2012 RECEIPT #. . . . . . . . . : BS000017026 REFERENCE ID #. . . . : 12060050 SITE ADDRESS . . . . . : 22791 MEDINA LN SUBDIVISION . . . . . . : CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : YUJING WU ADDRESS . . . . . . . . . . : 22791 MEDINA LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVEDFROM . . . . : BELL CONSTRUCTION CONTRACTOR . . . . . . . : JONG NAM KIM LIC # 28151 COMPANY . . . . . . . . . . : BELL CONSTRUCTION ADDRESS . . . . . . . . . . : 1373 RAMON DR CITY/STATE/ZIP : . . : SUNNYVALE, CA 94087 TELEPHONE . . ... . . . . : (408) 202-8370 FEE ID UNIT QUANTITY AMOUNT 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 1WINREP EACH 8 7. 00 392 . 00 0. 00 392 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 393 . 50 0. 00 393 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- --- CREDIT CARD 393 .50 VISA --------------- TOTAL RECEIPT 393 .50 Community Development Q�- 10300 Torre Avenue �j Cupertino CA 95014 Telephone(408)777-3228 U7y OF Fax(408)777-3333 CUPEkTINO Building flee artment JOB ADDRESS: q I Mpd i n A `A-. PERMTT# I GA OWNER'S NAME: Nr'h I Wo PHONE # GENERAL CONTRACTOR: s. NJ P M FAX # I am not using any subcontractors: /2, 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 Ornamental Sheet Metal . 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: 22791 MedinaiLane DATE: 06/06/2012 REVIEWED BY: Sean 10 APN: BP#: 'VALUATION: $4,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK Remove and replace 6 windows and 1patio door. SCOPE .Llecb. Plem Cheek Plumb. Plan Cbec6 Elec. Plan Check ,LL•eh, Prnnil Foe: Plumb.fermi/Fee: 1.7w. Permir Fra: t"lncur,11e,h, Invil Olhe, Plumb Insp. Li Odrrr like.Invp. Ej .Ilech./,?,p. Fee: Plumb. Irrsp. Fre: Oce.lnsp. Fee: NOTE: This estimate does nor ineludejees due to other Departments(Le Planning, Public Works, Fire,Sanitary Sewer District,School District,etc.). These fees are based on the relimina information available and are only an estimate Contact the De t or addn7 info. FEE ITEMS (Fee Resolution I1-053 EIL 71111 1) FEE QTY/FEE I MISC ITEMS Plan Check Fee: $0.00 = # Window/Sliding Glass Door Suppl. PC Fee: (D Reg. 0 OT FO.OThrs $0.00 $392.00 IWINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.0 Reg. 0 OT F0,0Thrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Conslruc/ion 7ax: Adininisfrenice fee: 0 Work Without Permit? 0 Yes (E) No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential (7 Building or Structure 0 Trurul l�odrmenluliurr Fees: � Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $392.00 TOTAL FEE, $393.50 Revised: 06/05/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildinala�cupertino.cra ❑NEW CONSTRUCTI��,�ONpppp ❑ ADDITION i ALTERATION/Tl //Tl ❑ REVISION/DEFEEP-UD I/O)INAL PERMT I .Y PROIECT.4DDRE55 �/J' I �a ` LlOu C1 OWNER NAME STREET ADDRESS 22 I / ju I n L1�(/4me QTY. STATE.IIP (r 1 � yi o r ( /4 gLvi FAX . CONTACT NAME I �,�-�-uC-1 I PHONE �7-y-_--,nr�•I fy� O E-MAILI S STREET ADDRESS j3�]3 l�rnDn' Or CITY.STATE. ZIP L(/lf) V;,1,e FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT L=r CONTRACTOR ❑CONTRACTORAGENT ❑ ARCTI ECT ❑ENGWEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME n I I /I _ ����tM LICENSE NUMBER �00 LICENSE TYPE 6 BUS.LIC d n I I COMPANY NAME CJ/L y Mc-m W t�I ,' \ EMAIL FAX . <-O r STREET ADDRESS STATE �" , ,IIP PHONE (31� ( i,Wl n lir CITYL4hn dr~I, C1-49Y-0 � 2DL—Q3� ARCHrfECT/ENGINEER NAME IJCENSE NUMBER BUS.LIC p COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,71P PHONE DESCRIPTION OF WORK r/J!7 EXISTDtG USE PROPOSED USE CONSTR TYPE MSTORES L / USE TYPE OCC SQ-FT. VALUATION(5) FSISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET.AREA BATHROOM KTCHEN REMODEL AREA REMODEL AREA REMODELAREA PORCH AREA DECKA TOTAL DECKIPORCH AREA I GARAGEAREA DETACH ATTACH a DWELLING UNITS IS A SECOND UNIT YES SECONDSTORY ❑YES BEING ADDED! O ADDITION' P90 PRE-APPLICATION YES IF YES.PROVIDE COPY OF LSTHEBLDGAN YES RE BY: TOTAL VALUA77ON: PL4NTIDIG APPLd NO PIwNND1G MPROVAL LETTER EICBI�R Hem, O By my Signa elow,I certify to each of the following: 1 am the property owner or authorized agent to act on die pr;perty owner's behalf. 1 have read this application and the information I have provided is correct. I have read the Description of Work and verify it is actuate. I agree to comply with all applicable local ordinances and state laws relating to building construction. 1 authorize representatives of Cupertino to enter the above-identified perry for inspection purposes. Signature of Applicant/Agent Date: i� ' SUPPLEMENTAL INFO TION REQUMED PLAN CHECK TRE UT ROING SLIP &/ New SFD or Multifamily dwellings: Apply for demolition permit for OVER-THE.COUNTER BUILDING PIAN REVIEW existing building(s). Demolition permit is required prior to issuance of building / permit for new building. ❑ EXPREBS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FmE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ NLAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doe revised 06/21/1/