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10110129 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADLRESS: 7941 OCTOBER WAY CONTRACTOR:TBD-TO BE PERMIT NO: 10 110 129 iDETERMINE11 OWNER'S NAME: YOUNG JIU XIE DATE ISSUED: 11/18/2010 'ER'S PHONE: 4086910106 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ c� WINDOW REPLACEMENT 8 WINDOWS,LIKE FOR LIKE License Class�,� Lic.# 3 6 Z / ALUMINUM TO VINYL,DOUBLE PANED,AND 1 PATIO DOOR Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 (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. Sq.Ft Floor Area: Valuation:$6500 t. 1 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 APN Number:36212028.00 Occupancy Type: performance of the work for which this permit is issued. 2. 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. A4, " , PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by: ! Date: 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 perm'. Additionally,the applicant understands and will comply with all non-point source a ulations per the C rtino Municipal Code,Section 9.18. RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is Signature Date j g r 0 installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1. 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 HAZARDOUS MATERIALS DISCLOSURE sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air 1. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 2. I have and will maintain Worker's Compensation Insurance,as provided for by Owner or au ized agent: Section 3700 of the Labor Code,for the performance of the work for which this Date: / O permit is issued. s. I certify that in the performance of the work for which this permit is issued,I shallCONSTRUCTION LENDING AGENCY 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 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.) become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the L ng of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date �,Avrcf Y�, Q0 ,A Q0 14-3 IZ N P N USI SIGNED m s and ind it Is 5 This 01 plan a alterations the lob J 'Alte .,ept 00 t M&e any from anlaul to Without ,,_,#ne w the The Skan)pinq �6xp NO, al 01 We O :zz x CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 7941 October Way DATE: 11/18/2010 REVIEWED BY: jsg APN: BP#: *VALUATION: 1$6,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex TOT'lf, PENTAMATION 1GENRES USE: 7'L.��t�/t .t Ii f=-�: PERMIT TYPE: WORK SCOPE a1 <:G. l'I:rr�('f�ec ,:,,,;/, r 'm t G� -1 t`Jr.x'?; 1-lcch 1""t wil !""c' oilier tfec fir. hiv, Li _L_ fhh:­P, ui:I re >.,,�., ',yet I�r/� Li 111,1111h Instr /,cc, 1 p. NOTE. These ees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (Fee Resolytion 09-051 Eff. T'1;10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 9 # Window/Sliding Glass Door Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 $506.00 1 WINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Feer Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ("onso-11c lion Tax Acoustical Fee: 0 Yes (F) No $0.00 Work Without Permit? 0 Yes E) No $0.00 Planning Fee: $0.00 Select a Non-Residential 7i~tri>c�l 1?c�ctrir7��tft�tic>ii l��t°.r Building or Structure Strong Motion Fee: IBSEISMICR $0.65 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: 1 $1.651 $506.00 TOTAL FEE: $507.65 Revised: 11/08/2010 CITY OF C UPERTINO CITYof CUPS TING GENERAL BUILDING PERINUT APPLICATION FORM APN# 42- /A ©iZ8 Date: 0 Building Address: Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes ❑ No HOA: (Exterior work only) Yes ❑ No If yes,provide letter from HOA Owner's Name: , Phone#: L10 C� _ O/0 .:lou JlLA X I -e- Contractor: eContractor:0 Phone: -6 So - '�L l o '4 rew wJ is d o w Fax: Contrctor License#: Y6 d 1-1 c-4 L Cupertino Business License#: Contact: Phone: 6 so rn r Fax: .<.esidential Commercial Job Description: S —,i u a o w S 3 1 p$ e/ rey-(Q C e-w e zz � /, k JCS, Gt�'u wr i tr u V" V �' (, of o k.c 13-r'e Building Permit Info: ' Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ E/=V-A '❑ II/III B, IV-HT, V-B ❑ �� Valuation: Square Footage: 6 Soo. c,o Project Size: Express ❑ Standard ❑ 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. "noints Achieved: or help, contact Build it Green at www.builditzreen.oriz Revised 07/14/09