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10010180 CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR:WANG GENE S CHIN AND PERMIT NO: 10010180 BUILDING ADDRESS: 20573 RODRIGUES AVE KRISTINE 20573 RODRIGUES AVE DATE ISSUED:01/29/2010 'NER'S NAME: WANG GENE S CHIN AND KRISTINE PHONE NO: CUPERTINO CA,CA 95014-4350 OWNER'S PHONE: 4082550133 ELECT PLUMB 0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r License Class Lic.# M ECH RESIDENTIAL COMMERCIAL Date Contractor JOB DESCRIPTION:DEMO SWIMMING POOL I hereby affirm that I am licensed under;on 3 of the Business&Professions he provisions of Chapter 9 (commencing with Section 7000)of Divis 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 hef--Labor Code,for the Compensation,as provided for by Section 3700 o Valuation:$700 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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 Occupancy Type: APN Number:35910048.00 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and stte that and ate laws relating PERMIT EXPIRES IF WORK IS NOT STARTED ation is correct.I agree to comply with all city and county construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE O to building purposes. (We)agree to save upon the above mentioned property for inspection against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cup g � costs,and expenses which may accrue against said City in consequence of the J l _..... �---" Date: 2- granting ,- granting of this permit. Additionally,the applicant unodMu�?dpal Codewill Section Issued by, :� �^� with all non-point source regulations per the Cup 9.18. Date •atu% RE-ROOFS: All roofs shall be in prior to any roofing material being installed.If a roof is OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one o Date: the following two reasons: Signature of Applicant: 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 sale(Sec.7044, S TO BE CLASS"A"OR BETTER Business&Professions Code) ALL ROOF COVERING 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three 05 25533,and 25534. I will maintain I have read the hazardous materials requirements under Chapter 6.95 oft e declarations: ' ain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 255al Code,05, 9.12 and the Health& I have and will maintain for b Section 3700 of the Labor Code,for the compliance`�'i Section 25532(a)should Istore or handle hazardous material. Compensation,as provided y Safety Code,S h emit hazardous air performance of the work for which this permit is issued. for b Additionally,should I use equipment rr devices is Management District I will I have and will maintain Worker's Compensation Insurance,as provide y contaminants as defined by the Bay Area Air Quality Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Labor Co is issued. Health&Safety Code,Sections 25505,25533,and permitf I certify that in the performance of the work for which this permit is issued,Ishall - manner so as to become subject to the Workers Owner or thorized agelrt: Date: not employ any person in any ! Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must CONST UCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked I hereb affirm that there is a construction lending agency for the performance of work's Y ICATION for which this permit is issued(Sec.3097,Civ C.) APPLIC ANT CERTIF I certify that I have read this application and state that the abo and state laws relating ation is Lender's Name correct.I agree to comply with all city and county ordinances 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 unify 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 Licensed Professional 9.18. / Date Signature .0k CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg 3 ITEMS OF 3 COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35910048 . 00 DATE ISSUED. . . . . . . : 01/29/2010 RECEIPT # . . . . . . . . . BS000009655 REFERENCE ID # 10010180 SITE ADDRESS 20573 RODRIGUES AVE SUBDIVISION : : : : : : . CUPERTINO CITY • IMPACT AREA . . . . . . : ER WANG GENE S CHIN AND KRISTINE OWN ; 20573 RODRIGUES AVE ADDRESS • • • • • . . ' ; CUPERTINO CACA 95014-4350 CITY/STATE/ZIP . • • , RECEIVED FROM . . . . : KRISTINE Y WANG CONTRACTOR . . . . . . . LIC # *OWNER* COMPANY WANG GENE S CHIN AND KRISTIN COM : 20573 RODRIGUES AVE ADDRESS . . . . . . . CUPERTINO CACA 95014-4350 CITY/STATE/ZIP . . . , TELEPHONE . . . . . . . • • PD-TO-DT THIS REC NEW BAL UNIT QUANTITY AMOUNT - ----__---- FEE ID ---------- ---------- --------- 1 0 . 00 ---------- --------- ---- ----700 .00 1 . 00 0 .00 0 . 00 1BCBSC VALUATION 0 . 50 0 .00 0 .50 0 .00 700 . 00 0 .00 490 . 00 1BSEISMICR VALUATION 0 .00 490 . 00 _ __________ 1DEMOPRE SQUARE FEET __________ ___-_----- --------- 0 ,00 491 . 50 0 .00 491 . 50 TOTAL PERMIT PAYMENT AMOUNT REFERENCE NUMBER METHOD OF P --------------- -------------------- CREDIT CARD -491_50 VISA TOTAL RECEIPT 491. 50 VOICE ID DESCRIPTION VOICE ID ----DESCRIPTION--------- -------- ---------------------------- 704 DEMO CITY O-F CUPERTINO DEMO y�cl PERMIT APPLICATION FORM CUPEiZTINO Date: �!)S C Building Address: � �y/,`41 u ): Mailing Address (if different from buildin address 7( Phone: owner's Name: Phone Contrac r: � Fax: Contractor License #: Cu ertino Business License#: Phone: Contact: Fax: Residential �Footage Commercial ❑ Sq Footage � Job Description: I` Valuation: Project Size: Express 9,, --S--tandad❑ Large❑ Major❑ Proj application Please complete relevant portions of the Greensheet index. Checklist & attach it to the or if applicabling e, include on the plan set & t Fee ID Fee Description Fee Group Permit Type Quantity g 1SFDWL-DEM 1DEMORES Demo-Residential 1DEMOPRES Pool Demo Residential B 1SFPOOL-DE1Vf B ALL PERMIT 1BCBSC Cal Bldg Standards TYPES Commission Fee B / 1BSEISMICRE Seismic Residential Revised 01/07/09 pWNER BUIL DER VERIFICATION one I or my immediate family (parent, spouse or child)will perform: 1• (Check ) A. Ali the work authorized by this permit A portion of the work B. — None of the work IfBo r C is checked,co m Tete 2 or 3 below. 2. A state licensed contractor will be hired to do: All of the work A. — the work (complete section below) B _ A portion of a of work to Address/City Phone # State License be ense # Type oimed Contractor immediate family to perform all or I will util ize unlicensed person(s) other than my to er (see reverse side). A em 3 _ work. I understand that I may bean n file at the City of portions of the authorized orkers' Cupertino Builcompensation must be o Certificate of Insurance covering office. Cu ding Department p Type of work to be A ddress/City Phone Number erformed Person/Firm ................................................ ........ ................................... and understand the • the above is true and correct. I have read that � I declare under penalty of perjury se side). ilder Information(rev Owner Bu -..A� Date: Signature: f0 V V 0 Property owner Permit# b Address: '�` e Ci of Cu ertino Bui jo • n this f orm shall be submitted to t An chap es to the information rovided o Department.