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09100133CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10211 COLBY AVE CONTRACTOR: TBD - TO BE DETERMINED PERMIT NO: 09100133 DATE ISSUED: 10/21/2009 OWNER'S NAME: FELIX KWOK PHONE NO: AER'S PHONE: 4089968181 ' ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F_ ELECT PLUMB F� License Class Lic. # 4"MECH � RESIDENTIAL � COMMERCIAL � Contractor Date JOB DESCRIPTION: 8'X12' REPLACE GYPBOARD, REPLACE I hereby affirm that I am licensed and r the provisions of Chapter DAMAGED (commencing with Section 7000) of Division 3 of the Business & Professions INSULATION.(LIVING ROOM CEILING WATER DAMAGED); Code and that my license is in full force and effect. SUMMIT BLDG CONSTRUCTION PD FOR BUS LIC 10/21/2009 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. 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 Sq, Ft Floor Area: Valuation: $2600 permit is issued. APPLICANT CERTIFICATION APN Number: 31628041.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. / Date:f6-- — �� Issued I y Signature �!�4 Date ❑ OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Date: Business & Professions Code) Signature of Applicant: 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 declarations:HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must Owv r authorize agent: / Dated/O G� forthwith comply with such provisions or this permit shall be deemed revoked. � 0 ENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name ur^- the above mentioned property for inspection purposes. (We) agree to save nify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address 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 9.18. I understand my plans shall be used as public records. Signa Date /0 Licensed Professional 3 ITEMS OF 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 31628041.00 DATE ISSUED.......: 10/21/2009 RECEIPT #......... BS000008984 REFERENCE ID # 09100133 SITE ADDRESS .....: 10211 COLBY AVE SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER FELIX KWOK ADDRESS ..........: 10211 COLBY AVE CITY/STATE/ZIP CUPERTINO CA, OPERATOR: patg COPY # : 1 95014-4719 RECEIVED FROM SOON T HONG 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 -------------------- 2,600.00 1.00 0.00 1.00 0.50 0.00 0.00 1BSEISMICR VALUATION 2,600.00 0.50 0.00 0.00 379.00 1INSP<=2HR HOURS 1.00 379.00 ---------- ---------- ------0_00 ---------- 380.50 0.00 380.50 0.00 TOTAL PERMIT METHOD OF PAYMENT AMOUNT REFERENCE -- NUMBER ------- ----------------- --------------- CREDIT CARD 380.50 VISA --------------- TOTAL RECEIPT 380.50 v9,vo�33 Ptvk. CITY OF CUPERTINO CUPEf�TiNO GENERAL BUILDING PERMIT APPLICATION FORM U � Date:/D APN #2/ A O a o ` Building Address: ress: , Mailing Address (if diffe ent from building address): Are Hazardous Materials being used as part of this project? Yes U No HOA: (Exterior work Owner's Name: :F Contractor: Contractor License #: Business License #: Contact: Yes n No V& If r 'a93/ . [de letter from HOA Phone #: 1 q96 -� �lgl IoAVFax: Phone: Fax: Residential Commercial U Job Description: /X 57yf f#0,,9 -D - Building Permit Info: Elect ' Plumb ElMech El Bldg � Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B Valuation: Square Footage: Project Size: Express [ !" Standard U Large or Green Building: Please complete relevant portion of the Green Building/UhEll k,necxubt M atIt"%,.. _` to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.buildit2reen.org Revised 07/14/09 to-Ws; CITY OF CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) additional stucco application B 1 WINREP Replacement windows/sliding glass door (ea 8 windows) B 1 WINMEWSTR New Window -structural shear wall/masonry (includes plan ck fee) B 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK 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 when not over counter) Standard Plan Check (when no E/M/P) hourly -stand alone B 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel & Documentation B 1BUSLIC Business License B 5 of 5 n CITY OF %'UPEI�TINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: 16-211 B Litz- ,' � 6q PERMIT # !'�'�� D�� OWNER'S NAME: ' PHONE # GENERAL CONTRACTOR- FAX # I am not using any subcontractors: �d 2 Signature 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 Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date