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10040137 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21911 DOS PALOS CT CONTRACTOR:QUALITY BUILT PERMIT NO: 10040137 CONSTRUCTION "VNER'S NAME: WEN&SHERRY CHEN 1160 DANBURY DR DATE ISSUED:04/22/2010 v vVNER'S PHONE: 4082579140 SAN JOSE,CA 95129 PHONE NO:(408)666-6096 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I- ELECT r PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:UPGRADE SERVICE PANEL FROM 125 AMP TO 200 AMP 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: 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:$500 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:32645017.00 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 Municipal Code,Section Issued by `-�'� Z_----2 Date: y 1 9.18. c;^nature Date RE-ROOFS: ON 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Oaf` or authorized a ent: Compensation laws of California. If,after making this certificate of exemption,I Date: 2 b become subject to the Worker's Compensation provisions of the Labor Code,I must /, —I)- forthwith comply with such provisions or this permit shall be deemed revoked. 1 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 the above mentioned property for inspection purposes.(We)agree to save nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. (`1 / Licensed Professional Signature I "► "' Date �' CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32645017. 00 DATE ISSUED. . . . . . . : 04/22/2010 RECEIPT # . . . . . . . . . BS000010241 REFERENCE ID # 10040137 SITE ADDRESS 21911 DOS PALOS CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER WEN & SHERRY CHEN ADDRESS 21911 DOS PALOS CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHYN YUN CHEN CONTRACTOR MARK NAUGLE LIC # 31678 COMPANY QUALITY BUILT CONSTRUCTION ADDRESS 1160 DANBURY DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95129 TELEPHONE (408) 666-6096 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ____ -- ---------- --------- ----------- ---------- 1BCBSC VALUATION 500 .00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 500 .00 0 . 50 0 . 00 0 . 50 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 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 .00 -----42_00 ------0_00 ---------- ---------- TOTAL PERMIT 127 .50 0 . 00 127 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------ CREDIT CARD 127 . 50 VISA --------------- TOTAL RECEIPT 127 .50 3-7 CITY OF CUPERTINO CUPEI�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN #3A Date: Building Address: Mailing Address (if different from building address). Are Hazardous Materials being used as part of this project? Yes Ll No [� HOA: (Exterior work only) Yes ❑ No If Yes, provide letter from HOA Owner's Name: Phone#: Contractor: Phone: r c.. i Fax: 4r c Contractor License It: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial ❑ Job Description: 4:e/W �6:p�.�t 1 U).. /21 I+r7- Building Permit Info: Bldg ❑ Elect J1 Plumb ❑ Mech ❑ 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 [�I�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. Points Achieved: For help, contact Build it Green at www.builditgreen.org Revised 07/14/09 CITY OF CUPERTINO an OF GENERAL BUILDING APPLICATION CUPEkT NO 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) IEPERMITFEE 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 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 1TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5of 5 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �-' / pS vi LI� PERMIT# � 0 v u 6/ OWNER'S NAME: �N PHONE# �O __6 GENERAL CONTRACTOR: ,,• USINESS LICENSE# `—�� V ADDRESS: I I bo S `�S/ CIT /ZIPCODE: *Our municipal code requires al businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable 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 Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date