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12100066 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20609 SHELLY DR CONTRACTOR:WANG'S PF,RMITNO: 12100066 CONSTRUCTION CO ONVNERSNAMF: CHL•NHUNGANDCHYULINGLING PO BOX 4802 DATE ISSUED: 10/092012 OWNER'S PDONF,: ELDORADO HILLS,CA 95762 PRONE NO:(916)941-2378 ❑ LICENSED CONTRACTOR'S DECLARATION .JOB DESCRIPTION: RESIDEN"1'IAL C1 COMMERCIAL License Class_ Lind 7 03 Z REPAIR DAMAGED BRICK AROUND THE CHIMNEY Contractor (1J e��jll� li?}�L(i�Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business S 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. Sq.Ft Floor Area: Valuation:$2000 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 ,U.N Number:35911020.00 Occupancy Type: permit is issued. APPLICA\1'CF,RTIFICA'IION 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 raid state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,mid hereby authorize representatives oflhis city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: SFR. /G�y Date: /I/). with all non-point source regulati7�7RE-ROOFS: o Municipal Cade,Section 9.18. Gy Signature Dale All roofs shall be inspected prior to any roofing material being installed.If a roof is / installed without first obtaining an inspection,1 agree to remove all new materials for inspection. ❑ NER-Bl1I I,DIiR DECLARATION 1 hereby affirm thatI nm exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BF,TITR 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 B Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to 1L\%ARDOUS DIATF,RIAIS DISCLOSURE construct the project(Sec.7044.Business d Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealh S Safer)-Code.Sections 25505,25533,and 2.5534. I mill 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino plunicipal Code,Chapter 9.12 and the declarations: llealth&Safer) Code.Section 25532(a)should 1 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 Management District 1 performance of the work for which this permit is issued e'ill maintain compliance is ith the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Workers Compensation Insurance,as provided for by the llealth R Safety Code,Sections 25505,255 .and 25534. Section 3700 of the Labor Code,for the performance of the work for which thisa ^� permit is issued. Owner or authorize)agent: )ate:- I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to became Subject to the Worker's Compensation laws of California. If,ager making this certificate of exemption,I CONSI'Rl1Cl'ION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLIC\NTCERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances mid 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 ,\RCII I"1'FCI"S DECLARATION and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I 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 - Date CONSTRUCTION PERMIT APPLICATION C COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228' FAX (408) 777-3333 ' buildinG(a)cupertino.oro I,;2/DOD 6 ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT PROJECTADDRESS 20 /-D r/� r APNN 3501 //_O�D OWNERNAME (J /P �L'LI/g 1 PHONE ,J E-MAIL tilt. tom( ( t//v STREETADDRESS I CITY, STATE,ZIP I FAX CONTACT NAMEr+I I LL\ . PHONE r{",(' 7 ��/!_�LC E-MAILL 1/J ��tl.�j//a/ yK� 1,C1� E �� STREET ADDRESS Orn % ✓�C.- �J - L Z `�I CITA �I`PS� �6 621. Fr� w 0OWNER 0OW7NER-BUILDER 0OW7NERAGENT CON'TRACTOROCONTRACTOR AGENT 0 ARCHITECT C1 ENGINEER 0 DEVELOPER 0TENANT CONTRACTOR NAME LICENSE NUMBER I LICENSE TYPE BUS.LIC0 COMPANYNAME �I E-MAIL FAX � /�• C� IL•`V .o STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC P COMPANY NAME E-MAIL FAX STREET ADDRESS I CITY,STATE,ZIP I PHONE DESCRIPTION OF WORK � /J 1 � � � l� 14 4R. 0L-'I"i R EVSTLY6 USE PROPOSED 'SE �^ CON�Tg./73gE z5t0i1lEs USE TYPE OCC. I SQ.FT. VALUATIONS) EMSTG NEW FLOOR DEMO COV /�TjOTAL C/ AREA AREA AREA NETAREA BATH:RGOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTALDECKIPORCH AAEA GARAGEAREN DETACH OATTACH z DWELLING UOTTS: ISA SECOND UNIT 1:1 YES SECONDSTORY OYES BELNGADDED' 0 N ADDITION! UNO PRE-APPLICATION UlTS IF YES.PROI'mE COPY Of IS THE BLDG AN OYES RECEIVLD' Y:11S Z TOTALVALUATION: PLMtNBNG APPLq UNO PLMNLNG APPROVAL LETTER EICtiLER i10t1E' UN0 By my signature below-,1 certify to each of the followin . I RM the property Owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information I have provided is comet. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b iIdine constructs n. Vulhorize represematives of Cupertino to enter the above-idcntifmd roperty for inspection.purposes. Signatureof Applicant/Agent: Date: SUPPLEMENTAL INTOUIATtON REQUIRED 2 �'0'CI'x'��� 5W R- '�'- +n--'" �qE. p�PL4.Y,CIiECK;T1'1'E�C�.',`.t�`.-y>�+j ��ROUTINGSCti'�•.S_„+.: Neal SFD or Multifamily dwellings. Apply for demolition permit for n o ' 4 t% x. f0%T1 - Kt OVER:TUE-COU\TER ,.�❑- rBU1LD1\OI'LV\NL\IE\V' existing building(s). Demolition permit is required prior to issuance of building -� permit for new building. E�rsess � i, Pu\\-I�cPw,"ae�Tewe , _Commercial Bldgs: Protide a completed Hazardous Materials Disclosure J❑�'srAN TonANu " � { � ❑o PUBLIC\CORRs � � ' rn if any Hazardous Materials are being used as part of this project • © LAIiCL .S�'+i '\' - ® FIRL ULT 'I' � j _Copy of Planning Approval Letter or Fleeting With Planning prior to �� \LAJOR ' °❑' SANITARY.�SEt\EN 0157 A.M. submittal of Building Permit application. `� i., l„r1, P. r., ..y t r cTir,=ie � '. 6+,�ilb. ❑; eN11�ROMNIEniT�ALi ,1 L7H . BldgApp_2011.doc revised 06/31/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 20609 Shelly Drive DATE: 10/09/2012 REVIEWED BY: Sean APN: BP#: 'VALUATION: $2,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1CHIMNEY USE: PERMIT TYPE: WORK Chimney Repair SCOPE Alech.Plan Check Phonh. Plan Check Flec.Plan Check Meth. Penni/Fee: Plumb. Permit Fec•: Elec. Perndt Fee: Other Arech.Insp. Od,e+•Plumb lnsp. Li I Other Elec.hap. .11e.ch.hup.Fee: Plumb. hisp. Fee: Elce.hap.Fee: NOTE: This estimate floes trot include fees true to other Departments(i.e. Planning, Public Bbrks, Fire,Sanitary Sewer District,School District,etc.). These feav are based on the prelitninan information available and are only rot evi tate. Contact rite De t or addn'I info. FEE ITEMS (Fee Resolution 11-053 Efl 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Chimney/Chimney Repair Suppl. PC Fee: (j) Reg. O OT 0.0 hrs $0.00 $534.00 ICHIANEYR I Chimney Repair PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.,0 Reg. Q OT FOOThrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Adininisirative Fee: Q Work Without Permit? O Yes Q No $0.00 E) Advanced Plannine Fec: $0.00 Select a Non-Residential Ti ave!Documentalinn Fete: Building or Structure 0 Strove Motion Fee: I1ISFIS6BCR $0.50 Select an Administrative Item Bide Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.501 $534.001 TOTAL FEE: $535.50 Revised: 10/01/2012