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09090181 CITY OF CUPERTIN!CONTRACTOR: BUILDING PERMIT BUILDING ADDRESS: 1272 POPPY WAY TBD TO BE DETERMINED PERMIT NO:09090181 DATE ISSUED:09/24/2009 OWNER'S NAME: EMILY CHANG PHONE NO: lER'S PHONE: 4083985588 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C i J Lic.# 8 333 8 MECH r RESIDENTIAL r COMMERCIAL Contractor ::viD Wk's f51 V CC Date '`�� JOB DESCRIPTION:100 AMP SERVICE METER MAIN PANEL& I hereby affirm that I am licensed under the provisions of Chapter 9 SERVICE RISER (commencing with Section 7000)of Division 3 of the Business&Professions PLACEMENT;TOP WEST ELECTRIC PAID FOR BUS LIC Code and that my license is in full force and effect. 9/24/2009 I hereby affirm under penalty of perjury one of the following two declarations: 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 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$1500 Section 3700 of the Labor Code,for the performance of the work for which this Sq,Ft Floor Area: permit is issued. Occupancy Type: APPLICANT CERTIFICATION APN Number:36619043.00 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 to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED 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 consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9Date:, .18. '=o Issued kms: Signature Date Z L OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.70441 Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous in S 5 of by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505 requirements25533,and pter 9 25534. I will Compensatin,as provided for 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 1 certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I 0y become subject to the Worker's Compensation provisions of the Labor Code,I must Owner orsutor � hi agent: _Date: r r forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state-that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save i,' inify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address L and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply 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 Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36619043 . 00 DATE ISSUED. . . . . . . : 09/24/2009 RECEIPT #. . . . . . . . . : BS000008756 REFERENCE ID # . . . : 09090181 SITE ADDRESS . . . . . : 1272 POPPY WAY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . EMILY CHANG ADDRESS . . . . . . . . . . : 1272 POPPY WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHRIS YANG 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 1, 500. 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 500. 00 0 .50 0 .00 0 .50 0 .00 1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 00 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 241 .50 0 . 00 241. 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 241 .50 VISA --------------- TOTAL RECEIPT 241 .50 Oct6� CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date: t G C.P I qC) 45. 2q Building Address: �;-7 '2-- f 0 C tit V Mailing Address (if different from building address): Are Hazardous Materials being used as part of this,project? Yes 0 No HOA: Exterior work only) Yes ❑ No "If provide letter from HOA Owner's Name: _ Phone#: Chan 40 , 3 �� S� Contractor: � Phone: 5 I 0 `` '107- 2-7-9I D r wut z-7l EG o C )✓t L- Fax: Contractor License#: CIO 9 3 3 3 °f Cupertino Business License#: Contact: f S Phone: r/n 2 07- 2 j 3 Fax: 92 ,f2 -- Residential Commercial ❑ �QriPC ., Job Description: /pv Amr S 5fpr(l/« `defer SPry�e yC/SPr Rflo/4cfm en-1 7 J ��f- 4000, Building Permit Info: Bldg ❑ Elect P 1 u m b ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV-HT,V-B R- i'dotnld , Valuation: t � �,� Square Footage: 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. Points Achieved: For help, contact Build it Green at www.builditgreen.org Revised 07/14/09 CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description FeeJlPermit Type GroGENRES or GENCOM 1STUCOAP Stucco Applications (up to 400 sfl B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window-structural shear B wall/masonry (includes Ian Ck fee) 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1MECPLNCK Stand Alone Mechanical PIn 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 hourl -stand alone 1BCBSC Cal Bldg Standards Commission Fee B AL TP ES 1BSEISMICR PERMIT i Seismic Residential B f IBSEISMICO Seismic Commercial B 1TRAVDOC Travel &Documentation B IBUSLIC Business License B 1 /�-r` 266 5 of 5 INPUT R&SOU-ces Energy •! M. ndoor Air uality an Fints es 1.Use Law/No-VOC PArd 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes 0 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7.Seal all Exposed Particleboard or MIS 4 IAQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes Jim 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 10.Install Whole House Vacuum System 3 IAQ/Health pts y—yes 0 1 1 N.Flooring 1.Select FSC Certified Wood Flooring B Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 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: OF 1301 57 Total Points Project Received: 01 01 0 G:data/progs/greenbuildingguidelines/remodelers/greenpointsfinal2.12.04protected.xis Community Development 10300 Torre Avenue X _ ' Cupertino CA 95014 he Telephone(408)777-3228 Fax(408)777-3333 CITY OF ,-UPERTINO Build in De artment JOB ADDRESS: PER # ()� 09 01 I W Cu pPrt�n C1) �Sv I Lk IO 7WNER'S NAME: 2,m i L Chi A PHONE # GENERAL CONTRACTOR: FAX# I am not using any subcontractors: Date Signature Please check applicable subcontractors and co m lete the followin information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical j p vjeiA dig- t C, Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ner/Contractor Signature Date