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11080095 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18830 TILSON AVE CONTRACTOR:AIR AND PLUMBING PERMIT NO: 11080095 SYSTEMS OWNER'S NAME: LAI TZE LEUNG TRUSTEE&ET AL 285 SOBRANTE WAY STE P DATE ISSUED:08/12/2011 ER'S PHONE: 6507767986 SUNNYVALE,CA 94086 PHONE NO:(408)733-2000 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class � 7 Lic.# L � r�f MECH RESIDENTIAL COMMERCIAL Contractor \, /" yr /y0/z}� l.2I hereby affirm that I am licensed under theisions of Chapter 9 JOB DESCRIPTION:ADD NEW GAS LINE FOR FLTI URE EQUIPMENT (commencing with Section 7000)of Divisionhe 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:$500 I 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 permit is issued. APN Number:37516048.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point sour regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. Z/�/ Signature Da Z l RE-ROOFS: L, OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliaJ ce with the Cupertino Municipal Code,Chapter 9.12 and the [certify that in the performance of the work for which this permit is issued,I shall Health&Safety(lode,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner or aut pfd agent: > / Compensation laws of California. If,after making this certificate of exemption,I i Date: [_ become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. f, CONSTRUCTION LENDING AGENCY I hereby affirmatthere is a construction lending agency for the performance of%ork's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save inify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18• Licensed Professional Signature Date rrviDD� GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC 408 777-3228 • FAX (408)777-3333 • building(E cuoertino.org CUPERTINO ( ) PLUMBING ❑1AF-CHAIMCAL ❑ELECTLL C - ❑MISCELLANEOUS PRt�jRI OJECT ADDRESS c (L A- l 1 PHONE l E-MAIL OWNER NAME � � (/ � STREET ADDRESS j / �S i�� CITY, STATE.ZIP / ��'L�f V vt, d FAX CONTACT NAME PHONE C E-MArr -T- --- STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BU=ER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACT ORAGENT ❑ ARCHITECT 13 ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME CENSE NUMBERL JC/` I ICENSE TYPE BUS.LIC# l COMPANY NAME FAX i �`G't ,�'��1�✓1 .I `�M, EMAIL STREET ADDRESS STATE.ZIP PHONE T 77 �� i1 t �/ t' ARCHITECT/ENGE-TEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 5E OF ❑SFD ar DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUII DING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONEp ❑NO IICHI ER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: j �?�,% RECEIVED BY: 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 have provided is c9frect.j 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 building cons ction.'I authorize representatives of Cupertino to enter the above-identifie prope for inspection pu{=poses. Signature of Applicant/Agent: - Date: �� SUPPLE AL RMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER Gy I^ ❑ EXPRESS U W ❑ STANDARD U Q ❑ LARGE ❑ MAJOR t1IEPMzsc,4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 18830 tilson ave. DATE: 08/12/2011 REVIEWED BY: bobs. APN: BP#: VALUATION: $500 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION 1 RPGAS USE: SFD or Duplex I I PERMIT TYPE: WORK add new gas line for future equipment SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00 - NOTE. These fees are based on the preliminary in ormation available and are only an estimate. Contact the Dept for addn 7 info, FEE ITEMS (Fee Resolution 11-0531. '{} ';'1.-'11) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: IIRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bldg,Stds Commission Fee: IBCBSC $1.00 $41.00 ]ADMIN SUBTOTALS: $154.501 $41.00 TOTAL FEE: $195.50 Revised: 07/04/2011 Building Department City Of Cupertino U12 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U PERTI NO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: l PERMIT# U OWNER'S NAME: PHONE# GENERAL CONTRACTOR: '/t z^ BUSINESS LICENSE# ADDRESS: , , K^ t_4-e-, CITY/ZIPCODE: 1_2j c4 *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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 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 1 rrr SiSignature Date