11020070 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10224 MINER PL CONTRACTOR:JIAN MIN CONSTRUCTION PERMIT NO: 11020070
OWNER'S NAME: JEN PING-HAUR&HSIAO WAN-YA 322 AVIADOR AVE DATE ISSUED:02/17/2011
OWNER'S PHONE: 4157168140 MILLBRAE,CA 94030 PHONE NO:(415)716-8140
C+ LICENSED CONTRACTOR'S DECLARATION r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# f F_ F F_
D MECH RESIDENTIAL COMMERCIAL
Contractor�T� 1 X10 i�.�, �17 w '�6ate� 11 t
I hereby affirm that I am licensed under the provisions of Chapt r 9 JOB DESCRIPTION:REMOVE UNPERMITTED STRUCTURE(GAZEBO)
(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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1500
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:31626082.00 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 source regulations per the Cupertino Munl 1pal Code,Section Issued by. Date: 2-r(/
9.18. /
Signature r Date
RE-ROOFS:
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:
I,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 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 Ow or authorized agent-
Compensation laws of California. If,after making this certificate of exemption,I < Dater
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
C and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
ag of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
wim all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31626082 . 00
DATE ISSUED. . . . . . . : 02/17/2011
RECEIPT # . . . . . . . . . : BS000012734
REFERENCE ID # . . . : 11020070
SITE ADDRESS . . . . . : 10224 MINER PL
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JEN PING-HAUR & HSIAO WAN-YA
ADDRESS . . . . . . . . . . : 10224 MINER PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JIAN GUO WU
CONTRACTOR . . . . . . . : JIAN MIN CONSTRUCTION LIC # 31489
COMPANY . . . . . . . . . . : JIAN MIN CONSTRUCTION
ADDRESS . 322 AVIADOR AVE
CITY/STATE/ZIP . . . : MILLBRAE, CA 94030
TELEPHONE . . . . . . . . : (415) 716-8140
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 500 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 500 . 00 0 .50 0 . 00 0 .50 0 . 00
1INSPMIS HOURS 2 . 00 252 . 00 0 . 00 252 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 253 .50 0 . 00 253 . 50 0 . 00
METHOD OF .PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 253 . 50 VISA
---------------
TOTAL RECEIPT 253 . 50
CITY OF 02,
CITY OF CUPERTINO
DEMO
CUPERTINO PERMIT APPLICATION FORM
APN# --� / 0 p� Date:
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Mailing Address (if different from building address):
Owner's Name: ( Phone:
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Contractor: Phone
Fax:
Contractor License #: cis-�- u I
Cu ertino Business License #:
Contact: Phone:
Fax/e-mail:
Residential [D1""'Sq Footage Commercial ❑ Sq Footage
Job Description:
Valuation:
Project Size: Counter ZI-_-Express ❑ 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-DEM
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 12/06/10