12110004 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10168 N PORTAL AVE CON"I'RAC`roRt -rMT—TT0 ff; PFRJIIT NO: 12110004
OWNER'S NAME: MR&MRS YEN DATE ISSUED: 11/01M12
OWNER'S PHONE: 4087471769 PIIONE NO:
❑, LICENSED CON'1'R,%CI'OR'S DECLARATION 302 DESCRIPTION: RFSIDFNI'IAI,LJ CONIMERCIAI.
License Class7L Lie.W g33,Y7 Z REPIPE SEWER LINE UNDERNEATH THE HOUSE
SEE NOTES
Contmeto vUi Date // O/
I hereby 1Tirm that I am licensed under the provisions of Chapter 9
(commencing with 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:
1 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.FI 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 die work for which this
QP6 10L,
permit is issued. ,11'N Number:3168053.00 Occupancy'1'ypr.
A PPIACANT CERTI F'ICATION
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 Imus relating
WITH
180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 D 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 / r- �f /
granting of this emit. Additionally,the applicant understands and will comply Issued bv: f Dale:
with all non-p at source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
" inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm that I am esempi from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVF-RINGS TO BE CLASS"A"OR BE'1'I'F.R
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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ILC-/-ARDOIIS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilea It &So fele Code.Sections 25505,25533,and 25534. 1 pill
hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Cade.Chapter 9.12and the
declarations: 1lcalth&Safety Code,Section 25532(x)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 a Bny Area Air Quality'Management District
performance of the work for which this permit is issued. will maintain compliance with 1 e Cupertino Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by [lie Health&Safety Code Sec un 5- 5.25533,and 25534.
Section 3700 of the Labor Code,for the performance of work for which this
Owner nr authorized ager Dale:
permit is issued.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ miy person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby aftirn 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 permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICA\I'CERTIFICATION Leader's Address
I certify that I have read this application and state that the above information is
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, ARCA ITECl"S DECLARATION
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
GENERAL PERMIT APPLICATION1�x M E f
• ,� COMMUNITY DEVELOPMENT DEPARTI>7ENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255 \� w I .
SC
CUPERTINO (408)777"3228 • FAX(408)777-3333• buildina0cuoerino.ora - V\ '\e/'
9vLU–MBAIG -s❑MECHAMCAL ❑ELEC'PiUCAL
❑MISCELA
NEOUS
PROr17ADDRESS ✓ Awa /Oyu 2a 053
OWN7M E-MAIL T
611
!7 STILE ADDRESS C STA7'�ZIP _n I FAX
17
Cp C0I4TAC7 NAME PHONE I E-MAIL "I
SIR:c--f ADDRESS Cn,STATE ZIP FAX
❑ owmm ❑ OWNER-BUILD°.]t ❑ OP'N rpt AGrT'T ❑ COMRACTOR El CMM CTOR A0aT. ❑ ARC:..T1T ❑D•GWE ❑ D_'. PER ❑ T'_I LI T
�naAA// CO OR NAME IJCENSENUNSER 2'�r LC�J "("PE BUS.UCN
VV^^ COMP NAME E-MAIL uJIJ (,' FAX
qJ°Y STRF JDDRESS v �O
CITY,5TAT<_Z0.J o G C A 85132 "- ) H43 -Sb o
ARC HIT�MNGZI,=NAME LJCENSE NUTSER BUS.LIC B
COMPANYNAME' I E.WJL FAX
ST=ADDRESS CITY,STATE,ZIP PHONE
USE OF FD Sv DUPLEX El MU FAMRY I PROJECT IN WILDLAND E PROJECT IIS E)YES YES IS THE SLOG AN ❑ Y
❑
BUrC_DNG: COM.L cIAL UREAN INTrAFAC'_AR:t NO FLOOD ZONE ❑NO MCHL 9t HOME! ❑NO
DESCRIPiLON OF W R.K L'
e V
c
11.1` I AL2 deutjD IE — Fl
TOTAL VALUATION: OQ R`_CEIVED BY:
By my signature below,I cern to each of tic following: I am the property owner or authorized agent to act on th_pro rty owner's behalf. I have read:his
application and the imormafien I have pro) is correct. I have read the Description of Work and verify it is actvrxte ag;ee�o comply Wtith all applicable local
ordinances and state dews relating to building onsa cdon I zuthorize representadves of Cupertino to enter the above-idcntifietT'pro e—I:or irspecrion puff oses.
Sign=re of ApnlicandAgc:m Dare: rI G� Z
SUPP ?�'-TAI-I13FORMATION REQUMED OFFICE USE ONLY
y OVER-THE-COUNTER
r
❑ EXPRESS
U
m ❑ STANDARD
V
L
5 ❑ uttee
❑ NwoR
A�E?.VacApp_011.doc revised 06/11/11
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: counter
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31628053 . 00
DATE ISSUED. . . . . . . : 11/01/2012
RECEIPT # . . . . . . . . . : 2S000018463
REFERENCE ID # . . . : 12110004
SITE ADDRESS . . . . . : 10168 N PORTAL AVE
• SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MR & MRS YEN
ADDRESS . . . . . . . . . . : 10168 N PORTAL AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : PLUMBING TECH
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
---------- ------------- ---------- ---------- ----
-ADMIN HOURS 1 . 00 42 . 00 0 . 00 42 . 00 0. 00
1BCBSC VALUATION 2, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
12SEISMICR VALUATION 2, 000 .00 0 .50 0 . 00 0 . 50 0 . 00
1BUSLIC FLAT RATE 1 .00 119 . 00 0 . 00 119 . 00 0 . 00
1PPERMITFE FLAT RATE 1 .00 45 . 00 0 . 00 45 . 00 0 . 00
1PRSEWER UNITS 1 .00 23 . 00 0 .00 23 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 45 . 00 0 . 00 45 . 00 0 . 00
TOTAL PERMIT 275. 50 0 .00 275 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 275. 50 CHK
-------------
TOTAL RECEIPT 275. 50 -
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING