10030158 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6092 WILLOW GROVE LN CONTRACTOR:JACK TANG&EDITH ONG PERMIT NO: 10030158
OWNER'S NAME: JACK TANG&EDITH ONG 6092 WILLOW GROVE LN DATE ISSUED:03/26/2010
NER'S PHONE: 4086465767 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r— 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:RMV EXSTNG HOT WATER PIPES OVER ROOF,REROUTE
(commencing with Section 7000)of Division 3 of the Business&Professions ALL
Code and that my license is in full force and effect. HOT&COLD WATER PIPES INSIDE HOUSE THRU WALL&
CAP OFF ALL EXISTING PIPES,INSULATE HOT WATER
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.
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. Sq.Ft Floor Area: Valuation:$2800
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:37538018.00 Occupancy Type:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by:
V OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sectio 5505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must '
D
Date: 1
forthwith comply with such provisions or this permit shall be deemed revoked. Own thoriz a t: Z% ! o
APPLICANT CERTIFICATION CONSTRU TION LENDING AGENCY
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 I hereby affirm that there is a const ction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
it' -unify and keep harmless the City of Cupertino against liabilities,judgments,
k. and expenses which may accrue again said City in consequence of the Lender's Address
granting of thi a it.Additionally,t applican ds and will comply
with all non rce regulations er the Cue no Mu cipal Code,Sec on
9.18. ARCHITECT'S DECLARATION
Signature Date I understand my plans shall be used as public records.
ZLV �.�
Licensed Professional \
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37538018 . 00
DATE ISSUED. . . . . . . : 03/26/2010
RECEIPT #. . . . . . . . . BS000010043
REFERENCE ID # . . . : 10030158
SITE ADDRESS . . . . . : 6092 WILLOW GROVE LN
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JACK TANG & EDITH ONG
ADDRESS 6092 WILLOW GROVE LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : EDITH ONG
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY JACK TANG & EDITH ONG
ADDRESS . . . . . . . . . . : 6092 WILLOW GROVE LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 2, 800 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BPWATER UNIT 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1BSEISMICR VALUATION 2, 800 .00 0 . 50 0 . 00 0 .50 0. 00
1PPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0. 00
1PRREPIPE NO OF FIXTURE 5 . 00 55 . 00 0 . 00 55 . 00 0. 00
1TRAVDOC FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 182 .50 0 . 00 182 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 182 . 50 VISA
---------------
TOTAL RECEIPT 182 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 507 FINAL PLUMBING
OWNER-BUILDER VERIFICATION
1. (Check one) I or m immediate family (parent, spouse or child) will perform:
A. 4 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. V/ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
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.
Person/Firm Address/City Phone Number Type of work to be
performed
......................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct: 1 have read_ and understand the
Owner-Builder Information (rev se side).
Property Owner's Signature: Date:
job Address: tA�i<<t-W 4.0
vv , ( w -Permit# % `J
An changes to the information provided.on thisormesubmitted to the Ci of Cupertino Build
Department.
� v 15
r CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEY TING PERMIT APPLICATION FORM
APN# Date:
l _ � a 3 z ,
Building Address-,
I�C-yo r� ��-C___ n , 6 ,
Owner's Name:, Phone#`;0 �-
Phone#:
Contractor: Fax#:
VVI"
b I �
Phone#:
Contact:
Fax#:
Contractor License#:
Cupertin�Bllusi�ness License#:
Job Desct s `
Residential Commercial ❑
Valuation: ,
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
IPCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASC6M Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
- , CITY OF CUPERTINO
- `` REPIPE/SEWER/MAIN SERVICE
CITYCUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
r 1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1 TRAVDOC Travel & Documentation Fee B
1 BUSLIC Business License B
.Indoor it ua try and Finishes - -
1.Use LowMo-VOC Paint 1 IAQ/Health pts y=yes D
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0
3.Use Low/No VOC Adhesives 3 IAG/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y--yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all EVos%il i'artioleboard or UDF 4 IAQ/Health. pts y--yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes D
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes D
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use Rapidly 13anewaWe Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes D
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: 0 -- 0
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