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13010008CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18815 TILSON AVE CONTRACTOR: RRG CORPORATION PERMIT NO: 13010008 OWNER'S NAME: JEN WANG 4231 BUSINESS CENTER DR STE 12 DATE ISSUED: 01/02/2013 OWNER'S PHONE: 7347573912 FREMONT, CA 94538 PHONE NO: (510) 257 -1400 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # �` 1 PROPERTY LINE CLEAN OUT Date d L Contractor � r I hereby affirm 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: 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: $5000 I have and will maintain Worker's Compensation Insurance, as provided for by Section 3.700 of the Labor Code, for the performance of the work for which this APN Number: 37516034.00 Occupancy Type: 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 representatives of this city to enter to 180 DAYS FROM-LAST-CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We) agree save indemnify and keep harmless the City of Cupertino against liabilities, judgments, against said City in consequence of the Date f � costs, and expenses which may accrue Issued by: granting of this permit. Additionally, the applicant understands and will comply with all urce regulations per the Cupertino Municipal Code, Section 9.18. RE- ROOFS: Date ` Z 1 All roofs shall be inspected prior to any roofing material being installed. If a roof is Sig ture installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER- BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following 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) HAZARDOUS MATERIALS DISCLOSURE I, as owner of the property, am exclusively contracting with licensed contractors to construct 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 I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Code, Section 25532(a) should I store or handle hazardous declarations: I have and will maintain a Certificate of Consent to self - insure for Worker's Health & Safety 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 defineftthnB rea Air Quality Managemen t District I Municipal Code, Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by will maintain compliance w'no the Health & Safety Code, 5, 5533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agen Date: permit is issued. 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 become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, must work's for which this permit is issued (Sec. 3097, Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. 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 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 non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date ImCITY OF CUPERTINO 91 FEE ESTIMATOR — BUILDING DIVISION miADDRESS. 18815 TILSON AVE DATE: 01/02/2013 REVIEWED BY: MENDEZ b4" Pckwil APN: BP #: *VALUATION: 1$5,000 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex P F"C' PENTAMATION 1 RPSS USE: $0.00 PERMIT TYPE: WORK PROPERTY LINE CLEAN OUT Permit Fee: $0.00 SCOPE 0.0 NOTE. This estimate does not include fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School n-f."i nfn 1 Thocn are based on thv nrvliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 U 7f %1!12) FEE Plumb. Plan Check 0.0 hrs $0.00 t'r'�>s -. b4" Pckwil Plumb. Permit Fee: 1PPERMIT $0.00 1r,,P- Other Plumb Insp. 0.0 hrs Lj 11,1'(b, hii!). hcc, hl;,;/,', V"t. , F"C' NOTE. This estimate does not include fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School n-f."i nfn 1 Thocn are based on thv nrvliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 U 7f %1!12) FEE QTY /FEE MISC ITEMS Plan Check Fee: $0.00 1 # $23.00 Plumbing IPRSEWER Sewer, Sanitary Suppl. PC Fee: Q Reg. Q OT 0.01 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.S Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 C�c�nstt-�rcticin T�r.�: Administrative Fee: IADMIN $42.00 0 E) Work Without Permit? Yes (F) No $0.00 Advanced Planning, Fee: $0.00 Select a Non - Residential Building or Structure A Travel Documentation Fee: ITRAVD0C $45.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldy, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $133.50 $23.00 TOTAL FEE:' $156.50 Revised: 10/01/2012 C; �ST.7 ytS CUPERTINO ►. GENERAL PERMIT APPLICATION 4 MEP COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION O�0 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -3333 • building aaguoertino.org b MISIC r � ' UMBING ❑MECHANICAL []ELECTRICAL ❑MISCELLANEOUS PROJECTADDRESS Jfl�`�J%w APN# OWNER NAME 'T. S \J� C� �M � �.l V J PH� JJ A" -IS-) ' STREET ADDRESS I � �5>s" J CITY, STATE ��k'1 A n L4 o g� V �' r ` 'E- `MAIL' FAX CONTACT N �L ' iL PHONE 5 �,o) 25 l - �`lo STREET ADDRESS CITY, STAB � \�� 6\LAS�� FAX (`> ` i2 ❑ OWNER ❑ OWNER- BUIIAER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME ��1' � � 'CJ LICENSE NUMBED `, • ;, ��— , "� "� LICENSE TYPE BUS. LIC # CaMPANYNA IE � E -MAIL FAX STREET ADDRESS. CITY 5 ATE ZIP LIS 3y,', PHONE ARCJirCECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN Wn OLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK Vgl%,L EAAOLAa, ,- 3 S i ow S�`�0— eX-) L,t> tItL- .4,k_L J aQW� ZIC) �- TOTAL VALUATION: RECEIVED BY: By my signature below, I certify to each the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read thus application and the information I have p ed is correct I 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 bui ' constru ' n. I authorize representatives of Cupertino to enter the aboi q identied prope.:y for inspection puiposes. ISignature of Applicant/Agent: Da2e: 2 SUPPLEMENTAL INFORMATION REQUIRED OERCE USE ONLY OVER- THE - COUNTER c E- Y U v U ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR Al PMiscApp_2011.doc revised 06121111 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408 - 777 -3333 JOB ADDRESS: ! `,v-, 5 ►' \L.53� �/ PERMIT # OWNER'S NAME: PHONE # AOY k GENERAL CONTRACTOR: BUSINESS LICENSE # CA?214W ADDRESS: 44,72% t CITY /ZIPCODE: PtVw— N,0V -(r CX 53 *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 ONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: ` i_Lr3 Si g nature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date 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