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11100029 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11570 UPLAND WAY CONTRACTOR:BATH FITTER PERMIT NO: 11100029 NORTHERN CALIFORNIA OWNER'S NAME: TIEN WU 2118 ZANKER RD DATE ISSUED: 10/05/2011 `)WNER'S PHONE: 4087689204 SAN JOSE, CA 95133 PHONE NO:(408)834-1111 LICENSED CONTRACTOR'S DECLARATION F- t._ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# ( V J Contractor.&k Q( R �[�+� F er Date /D 5MECH RESIDENTIAL COMMERCIAL l( I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL NEW SHOWER VALVE ADD SHEET ROCK, (commencing with Section 7000)of Division 3 of the Business&Professions INSTALL ONE PIECE LINNER. 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:$1155 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 permit is issued. APN Number:36651003.00 Occupancy Type: 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 to building construction,and hereby authorize representatives of this city to enter WITHIN 180 S OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS 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 C /� granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: J [ with all non-point source regulat ns per the Cupertino Municipal Code,Section 9.18. ! Signature'/�_7 Date 1 1e RE-ROOFS: 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 OWNER-BUILDER DECLARATION inspection. I hereby affirm that I am 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 BETTER 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&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE 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. 1 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 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 the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Vunicipal Code,Chapter 9.1 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect' n 550 O 5 3,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this /t permit is issued. Owner or authorized agent. Date: 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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUC'T'ION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I 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 APPLICANT CERTIFICATION Lender's Address 1 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, ARCHITECT'S DECLARATION :ts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. anting 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 CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 36651003 . 00 DATE ISSUED. . . . . . . : 10/05/2011 RECEIPT # . . . . . . . . . : BS000014947 REFERENCE ID # . . . : 11100029 SITE ADDRESS 11570 UPLAND WAY SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER TIEN WU ADDRESS 11570 UPLAND WAY CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5104 RECEIVED FROM JOE WANNETTI CONTRACTOR BATH FITTER NORTHERN CALIFORNI LIC # 31358 COMPANY BATH FITTER NORTHERN CALIFORNI ADDRESS 2118 ZANKER RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95133 TELEPHONE (408) 834-1111 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL -------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 13CBSC VALUATION 1, 155 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BPFIXTURE NO OF FIXTURE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 1BSEISMICR VALUATION 1, 155 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1STINSP UNITS 1 . 00 130 . 00 0 . 00 130 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 269 . 50 0 . 00 269 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 269 . 50 visa --------------- TOTAL RECEIPT 269 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP CONSTRUCTION PERMIT APPLICATION 111 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228• FAX (408)777-3333• buildingC�cupertino.org CUPERTINt3 00v2-1� ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS i Its--7/,,, I e O` r,'^r(1 j 1 APN# l O 3, OO OWNERNAME \ li P�NOE lbs_ ,9),04 E-MAIL` y�o,[1A��/ STREET ADDRESS1(57, L ( 7, '�� J CITY�STATE\� OA T5 01 FAX CONTACT NAM PHONE E-MAILA"rI- STREET ADDRESS iJ/'ff �� _ D� CITY,STATE, ZIP ",40 r b ��/�I FAX /qV y �. I'n ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT v3 11 ARCHITECT ❑ENGINEER ❑ DEV/ELOPER ❑ TENANT CONTRACTOR NAME 4k LICENSE NUMBER9a3s9 3 LICENSE TYPE A- BUS.LIC# COMPAN"AME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP `T J qV2 U PHON 1\E3 q ARCHITECT/ENGINEER NAME jCC� C LICENSE NUMBER `J e, (J► BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS f/ CITY,STATE,ZIP PHONE DESCRIPTION OF WORKr.eIOCA IIS�IX�I.✓:P.�' o�-i'� ��l . �n�c��t' m„x. �� `x `, EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN _YES RECEI TOTAL ��ATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME.' NO /y J By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I hav rovided is o ect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relati . In co str tion. I authorize representatives of Cupertino to enter the abov ide tified property for inspection purposes. Signature of Applicant/Agent: Date: fb S lr� SUPPLEMEWA' FORNtATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ 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 ❑ FIRE DEPT — Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SAMTARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06/21/11