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09100059 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20545 BLOSSOM LN CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100059 OWNER'S NAME: EMILY CHEN DATE ISSUED: 10/08/2009 ER'S PHONE: 4086918940 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB License Class Lic.# 67& F MECH RESIDENTIAL COMMERCIAL Contractor ( L (;{)!�� ( (\)C—Date I c� (� 160 9 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD ELECTRICAL AND GAS METERS; DI LI (commencing with Section 7000)of Division 3 of the Business&Professions CONSTRUCTION Code and that my license is in full force and effect. CO. INC.PD FOR BUS LIC 10/08/09 1 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35918032.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrete against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18• Issued b - "�- Date: �G 0eF Signature Date t o b 1 6 07 V_ LI OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or t �ize�d age p become subject to the Worker's Compensation provisions of the Labor Code,1 must �� Date: 0 1,9120-07 20-0 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address i• -»fy and keep harmless the City of Cupertino against liabilities,judgments, C1, and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35918032 . 00 DATE ISSUED. . . . . . . : 10/08/2009 RECEIPT #. . . . . . . . . : BS000008869 REFERENCE ID # 09100059 . A% -e 2°y SITE ADDRESS . . . . . : 20545 BLOSSOM LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . EMILY CHEN ADDRESS . . . . . . . . . . : 20545 & 20549 BLOSSOM LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DI LI CONST CO. INC 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 000 . 00 1 .00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 000 . 00 0 .50 0 . 00 0.50 0 . 00 1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 00 0 .00 1EPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 1ERT<200 UNITS 1. 00 42 . 00 0 .00 42 . 00 0 . 00 1PGASRES OUTLETS 1. 00 63 . 00 0 .00 63 . 00 0 . 00 1PPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 .00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 346 . 50 0. 00 346 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 346 .50 #1302 --------------- TOTAL RECEIPT 346 .50 11,at CITY OF CUPERTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date: Building Address: 2 -5�4 i5 Z D � {-BLS&tib Mailing Address (if different from gilding address): C-A 0 Are Hazardous Materials being used as part of this project? Yes El No HOA: Exterior work only) Yes ❑ No Ej/tf es, rovide letter from HOA Owner's Name: Phone#: -F-H I L_ c 4-0& - 6 (N 00 o Contractor: Phone: o�— �7 i �--; C oN� Cc7 C 2sfi -Z` Fax: Contractor License t 6 t 8 g Cupertino Business License#: Contact: Phone: — 'rNNJ *- (" Fax: Residential Commercial El Job Description: -S-71 l£L�1�-��„P�� i� --Y�a� '�I'1-S-1 -F, Building Permit Info: Bldg ❑ Elect Plumb Mech o Type of Construction (Usage Class): Occupancy Type: ]�Val1-A, I-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B F,,- Valuation: uation: Square Footage: 0CCD Project Size: Express E6tandard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reen.or Revised 07/14/09 CITY OF CUPERTINO CITY of GENERAL BUILDING APPLICATION CUPEf�T1N0 FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B r P 6 a1'c a 5 of 5 � Iz -r<::�20 0 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 +kVUff OF Fax(408)777-3333 �UPEkTINO Buildin De artment JOB ADDRESS: PERMIT # OWNER'S NAME: ; L- PHONE # GENERAL CONTRACTOR:-b", o FAX# 4c&—966-s-9 I I am not using any subcontractors: C�)-,\ y Signature Date Please check apphcable 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ner/Contractor Signature Date