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09090041 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22489 WALNUT CIRCLE NORTH CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09090041 DATE ISSUED:09/09/2009 OWNER'S NAME: JIMING WANG PHONE NO: 4ER'S PHONE: 4089731390 ' ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Cr 4 Lic.# MECH f— RESIDENTIAL f— COMMERCIAL ContractorDate ^^�� JOB DESCRIPTION:INSTALL NEW GAS LINE FOR KITCHEN I hereby affirm that I am licens'E:d unser the provisio�Chpter COOKTOP ABOUT (commencing with Section 7000)of Division 3 of the Business&Professions 50-60 FEET;SMART PLUMBERS&ROOTERS PD FOR BUS Code and that my license is in full force and effect. LIC 9/9/9 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. I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$950 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: permit is issued. APPLICANT CERTIFICATION APN Number:35703061.01 Occupancy Type: 1 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, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point sou a regulations p he Cupertino Municipal Code,Section 9.18. �la Date: Issued V Signature Date Li OWNER-BUILDER DECLARATION RE-ROOFS: I 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, Date: / c7� Business&Professions Code) Signature of Applicant: (((((( 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 Chapter 5 of Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,he hazardous Sections 25505,2553r 9 I have read t and 25534. 1 will perforance of the work for which this permit is issued. maintain 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 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will I 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 ori : G� become subject to the Worker's Compensation provisions of the Labor Code,I must Own zed ge Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 1 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 unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address 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 Licensed Professional CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# -) C, Date: 4 D-) �r I o Building Address: Owner's Name: Phone#: 3 0 Contractor: Phone#: ) -� Fax#: Contact: Phone#: +O :�4o --� C-,-kap-4 Fax#: Contractor License#: GP-11:!�60pr Cupertino Business License#: Job Description: j�S-ea l J20,J s t'e - 6 ` 0 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: 0 Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM 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 CITY OF FEE SCHEDULE CUPEt�TINO Fee Description Fee Permit Type Quantity :Fee ID p Grou 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 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1BPFIXTURE 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 1TRAVDOC Travel &Documentation Fee B 1BUSLIC Business License B i M.Indoor Air Pity and Inishes 1 IAQ/Health pts y=yes 0 1.Use i�Io-VOG Paint 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 31AQ/Health pts y=yes 0 3.Use Low/No VOC,Adhesives 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 5.Use Engineered Sheet Goods with no added Urea 0 61AQ/Health pts y=yes Formaldehyde Y 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health P is Y= es 0 7.SOW aUEVosedPaWGboard,orMDF 41AQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0 10.Install Whole House Vacuum System 3 IAQ/Health pts y--yes 1 i 1 N.Flooring 6 Resource is es I 1.Select FSC Certified Wood Flooring P Y=y 2.Use Rapidly Renewable f=looring Materials 4 Resource pts y=yes 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 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 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 1 1 1 Total Points Available: 140 1301 57 0 Total Points Project Received: 0 0 G:data/progslgreenbuildingguidelines/remodelers/greenpointsfinal2.12.04protected.xls CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35703061. 01 DATE ISSUED. . . . . . . : 09/09/2009 RECEIPT #. . . . . . . . . BS000008624 REFERENCE ID # 09090041 SITE ADDRESS 22489 WALNUT CIRCLE NORTH SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER JIMING WANG ADDRESS CITY/STATE/ZIP CA RECEIVED FROM SMART PLUMBERS & RO 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 950 . 00 1 .00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 950 . 00 0 .50 0 . 00 0 . 50 0 .00 1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 .00 1PGASRES OUTLETS 1. 00 63 . 00 0 .00 63 . 00 0 .00 1PPERMITFE FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 .00 0 . 00 -----42_00 - ---- ---------- ---------- TOTAL PERMIT 262 .50 0. 00 262 . 50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -- CHECK 262 .50 #1621 --------------- TOTAL RECEIPT 262 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION --------- ------ ------------------- __ _ -- -- -------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING