09100056 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10630 JOHANSEN DR CONTRACTOR:YI JWU YANG&HSIU-HUI PERMIT NO:09100056
HSU
'NER'S NAME: YI JWU YANG&HSIU-HUI HSU 10630 JOHANSEN DR DATE ISSUED: 10/08/2009
OwNER'S PHONE: 4082552202 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT T_ PLUMB
License Class Lic.#
MECH f- RESIDENTIAL� COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FILL POOL
(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 Sq.Ft Floor Area: Valuation:$2000
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 APN Number:37536010.00 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 constriction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM 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
granting of this permit. Additionally,the applicant understands and will comply Issued by.,,:: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section r
9.18.
F' -ture Date
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
❑ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
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) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by 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
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall Ownerthorized agent:
not employ any person in any manner so as to become subject to the Worker's Date:-
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 CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
he above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
u, mify 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 so roe regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. '" _ }
Signature `" Date l d O
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37536010 . 00
DATE ISSUED. . . . . . . : 10/08/2009
RECEIPT #. . . . . . . . . : BS000008864
REFERENCE ID # . . . : 09100056
SITE ADDRESS . . . . . : 10630 JOHANSEN DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER YI JWU YANG & HSIU-HUI HSU
ADDRESS . . . . . . . . . . : 10630 JOHANSEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : HSIU-HUI HSU
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY YI JWU YANG & HSIU-HUI HSU
ADDRESS . . . . . . . . . . : 10630 JOHANSEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 2, 000 . 00 1 . 00 0.00 1 . 00 0 . 00
1BSEISMICR VALUATION 2, 000. 00 0 .50 0.00 0 . 50 0 . 00
1DEMOPRE SQUARE FEET 0. 00 490 . 00 0. 00 490 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 491 . 50 0 . 00 491. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 491 .50 MC
---------------
TOTAL RECEIPT 491.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child) will perform
A. All the work authorized by this permit
B. A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. All of the work
B. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
PersorVFirm Address/City . Phone Number Type of work to be
performed
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: t,._ ` - Date:
Job Address: 0 c �q Permit# 12��426 SSG
0901
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO
DEMO
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: -r `
:J
Mailing Address (if different from building address):
Owner's Name: I t i Phone:
Contractor: Phone
yA) JC1 Fax:
Contractor License #:
Cupertino Business License#:
Contact: Phone:
Y C)
" ax:
Residential ®--'Sq Footage Commercial ❑ Sq Footage
Job Description: ` :�C
Valuation:
i
Project Size: Express M----Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEMV
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 01/07/09