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10030183 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20273 NORTHCOVE SQ CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10030183 OWNER'S NAME: FUNG MICHAEL G DATE ISSUED:03/31/2010 'NER'S PHONE: 6502197210 , PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG[_ ELECT r PLUMB License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE SHOWER,REPLACE SINK VANITY,NO (commencing with Section 7000)of Division 3 of the Business&Professions ELECTRICAL/LIGHTING&NO MECHANICAL 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$3500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number:31641041.00 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 enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree too save 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 c consequence the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by:.- Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,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, Signature of Applicant: Date: Business&Professions Code) I,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 I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by 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 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 Compensation laws of California. If,after making this certificate of exemption,I Owner authoriz nt: become subject to the Worker's Compensation provisions of the Labor Code,I must Date:3 3 [U forthwith comply with such provisions or this permit shall be deemed revoked. CONS ION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address it' nify and keep harmless the City of Cupertino against liabilities,judgments, 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 I understand my plans shall be used as public records. 9.18. Signature . Date 3 -bl E_0 Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31641041 . 00 DATE ISSUED. . . . . . . : 03/31/2010 RECEIPT #. . . . . . . . . : BS000010072 REFERENCE ID # . . . : 10030183 SITE ADDRESS 20273 NORTHCOVE SQ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER FUNG MICHAEL G ADDRESS 12585 MIRA LOMA WAY CITY/STATE/ZIP LOS ALTOS HILLS CA, 94024-4710 RECEIVED FROM . . . . : MICHAEL G FUNG 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 3, 500 . 00 2 . 00 0 . 00 2 . 00 0 . 00 1BSEISMICR VALUATION 3, 500 . 00 1. 00 0 . 00 1 . 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 84 . 00 0 . 00 84 . 00 0. 00 1PRSEWER UNITS 2 . 00 84 . 00 0 . 00 84 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 84 . 00 0 . 00 84 . 00 0 . 00 ---------- 255 . 00 0 . 00 255 . 00 0. 00 : TOTAL PERMIT METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ------- --------------- -------------------- CREDIT CARD 255 . 00 VISA --------------- TOTAL RECEIPT 255 . 00 '71 L-E 'Sif6u G - L\3 ihtS 5ho �jj e r-- © r T �A -71 c m IN At E �,ftf�,, .. I 'HF c:ITY o CUPI H1itj i. } DATE__� 3 lv SIGWEF:2�- This set of plans and specifications MUST be kept on the job at all times and it is lawful to make any changes or alterations same without written permission from 8 Building pe�rtment,Clty of Cuppeertino. (1� e tamping o this plan and specifications S ,�L NOT be held to permit or to be an approval of the violation of any provisions Of y City Ordinance or State Law. I Z fou (C. y Uo C-t3 c -I v CQ,CJA.Q B-e-d �C-)C) M CITY OF CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date; � � � qI - �� I . � - ; Building Address: Mailing Address (if different from building address): Are Hazardous Materials being usea as part of this project? Yes No E HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Owner's Name: Phone#: M t U4 P,-EZ Contractor: Phone: X49 7'-2-2— rl� L-- V Fax: Contractor License#: Cupertino Business License#: 7- Contact: Phone: Fax: Residential [ Commercial ❑ Job Description: R�R�-e, s, �K uAN ► 1� �-u M c=4lafkC A--z__._... Building Permit Info: Bldg [l/ Elect ❑ Plumb EJ--- Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [j-- R Valuation: Square Footage: Project Size: Ex ressStandard ❑ Lar e ❑ Maj or ❑ 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.buflditgreen.org Revised 07/14/09 st,94.1 CITY OF CUPERTINO C U CITY OF O GENERAL BUILDING APPLICATION 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) 1WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) 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 1 PLMBLNCK 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 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 101 S 5 of 5