13010074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 924 FERNGROVE DR CONTRACTOR:TBB—q'6-BE PERMIT NO: 13010074
DETERMINED
OWNER'S NAME: HSIU FENG WANG A c DATE ISSUED:01/142013
OWNER'S PHONE: 4088652456 n PHONE NO: -
❑ -LICENSED C I ONTRACrOWS DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL
License Cl Lic.N INSTALL PROPERTY LINE CLEAN OUT
r 9 *SEE NOTES*
Contract D
I hereb - m that I am licensed under the rovisionof Chapt 9 -
(comm net g with Section 7000)of Division o[the Business&Professions
Code, ad at 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. r ree• Valuation:$2200 ;
I have and will maintain Worker's Compensation Insurance,as rov' for
Section 3700 of the Labor Code,for the perfortnanceyq�he - for JPfTum 75 57.00 Occupancy e• -
permit is issued. . p y Typ
APPLICA(VT CERTIR TI
I certify that I have read this application and state th ve information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct:I agree to comply with all city and county ordinances and state laws relating WIT 80 DAYS OF PERMIT ISSUANCE OR
to building construction,sand hereby authorize representatives of this city to enter
upon the above mentioned property.for iii*cdon purposes. (We)agree to save 18)D OM LAST CALLED INSPECTION:'
indemnify and keep h less the City,of Cltpertino against liabilities,judgments,
costs,and expens ch may acerae against said City in consequence of the
granting of thiyj5ino. Additionally, applic understands and will comply Issued by: Date:
with all non- Dint- ur egulations the rtino Municipal ,Sec ion
9.Is
RE-ROOFS:
Si afar ate 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-DUILDER'DE TION
her y
IT that t am exempt from tC tractor's License Law for one of Signature of Applicant: Date:
the fo wing two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER'
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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
consuuct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 hereby affirmunder penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)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 1"'y
Area Air ality Management District I
performance of the work for which this permit is issued. will maintain compliance 'ih a upertino M ci Code,Chapter 9.1 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety fa�ftmction
25 5,255 ,a 5534. -
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized Date:
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 any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I ION LEND AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that th 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
APPLICANT CERTIFICATION 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 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 ARCHITECT'S DECLARATION
indemnify 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 son-point source regulations per the Cupertino Municipal Code,Section Licensed Professional -
Signature - Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DI
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �\ M '
CUPERTINO (408)7773228•FAX(408)777-3333• buildinD cuoertin0.0 \2
❑ SC
PLUMBBiNO []MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECTADDRESS L rJ / �� ' `/ n�'f APN# !2 0
5'"--7
ME
OWNER NAP`HONb/ �7�6r2 -
STREETADDRESS v � STATE,j��/O`/'TI �/a FAX
CONTACT NAME PHONE V� /V E-MAIL
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHTTECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME/�jJ�/ $E)iUAiBER�//7 [ LICENSE TYPE BUS.LC#
COMPANY NAME �I'/CJ) E.MAR. t/f% *0O`
STREETADDRESSZg5 /�Jyj� CTIY STA /� P 41/. - �J J
LA/4'2
ARCHTTECT/ENGINEER NAME LICENSE NMSER J BUS.LC# 7 E
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMB.Y PRO=BJ WRDLAND ❑ YES PROJECT RI [3 YES
IS THE BLDG AN ❑ YES
BUILDING: COMMERCIAL URBAN INTERFACE AREA ANO FLOOD ZONE ❑NO EICHLERHOME? C3 No
DESCRIPTION OF WOR%
TOTAL VALUATION: RECEIVED
By my signature below,I certify to each of o]] g. I am the property owner or autha ' agent to act on a perty owner's/behalf I have read flus
application and the information I have p ded is rrect. have read the Des 'on o and verify it is ac te. agree to comply with all applicable local
ordinances and state laws relatin to -din structi I authorize rep fives pertino to enter the ab i' dfiedp ertl for inspection put§oses.
Signature of Applicant/Agent 11Z Date:
S P EMENTAL INFORMATION REQT/ •FJCE USE ONLY
,� GVER-TxE-courvTER
❑ EXPRESS
Y
U
❑ STANDARD
U
❑ LARGE
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❑ MAJOR
MEPM=App_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 929 FERNGROVE DR DATE: 01/14/2073 7RFVIEWED BY: MENDEZ
AEN: 356 14 031. BP#: `VALUATION: 1$2,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY PENTAMATION
USE: - SFD Or Duplex PERMIT TYPE: 1 RPSS
WORK PROPERTY LINE CLEAN OUT
SCOPE
yy {
��
h&ch. Play Check - Plumb.Plan Check 0.0 1 hrs $0.00 Elec.Plun Check
. :bfecle_Permit Fee:: Plumb.Permit Fee: 1PPERHIIT Flee, Permit Fee:
Other A9e4h:1n.ep.. Other Plumb Insp. 0.0 hrs $45.00 Other 6lcc.Insp.
&fech./nsp.:Fee: Plumb. /nsp.Fee: flee.Insp. Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These fees are based on the prefintdn in ormadon available and are only an estimate. Contact the Dept for addn 4 info.
FEE ITEMS (Fee Resolution 11-053 E . 711/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Plumbing
Supp]. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $23.00 IPRSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee $45.00
Construction Tax:
Administrative Fee: IADMIN $42.00 0
Work Without Permit? 0 Yes iq No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential Q
Travel Documentation Fee; ITRAPDOC $45.00 Building or Structure
Strong Motion Fee:' 1ESEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1ECESC $1.00
$133.50 $23.00c� TOTt1.FEE`R $156.50
Revised: 10101/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: NC (� PERMIT#
OWNER'S NAME: PHONE#
GENERAL CONTRACTQ12i t✓ ?y//'l/ BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires:all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SU NTRACTORS BTAINED A CITY F CU ERTINO
BUSINESS LICENSE. 12,I am not using any subcontractors:, /
Signature Date
Please check applicable subcontr ors and complete the follo information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork '<
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/'•Contractor Signature Date