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09100197 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRES!i 1143 ELMSFORD DR CONTRACTOR:MICHAEL SHINING PERMIT NO:09100197 CONSTRUCTION INC TIER'S NAME: ALEX C WU&RANAN LIN 34140 AUDREY CT DATE ISSUED: 10/28/2009 OWNER'S PHONE: 4083728618 FREMONT,CA 94555 PHONE NO:(510)791-1588 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f- PLUMB License Class Lic.# MECH f— RESIDENTIAL f— COMMERCIAL � Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SWIMMING POOL(1924SQFT) (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 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 Sq.Ft Floor Area: Valuation:$7000 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 APN Number:36208016.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issu �: Date: e with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. -ture Date RE-ROOFS: All roofs shall be inspected 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 0-1 inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the stricture is not intended or offered for sale(Sec.7044, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 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 I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air 1 have and will maintain Worker's Compensation Insurance,as provided for by 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 Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Ownr o�authorized agent: CIA not employ any person in any manner so as to become subject to the Worker's A n n / �7��Date: O Z Compensation laws of California. If,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must - CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION Lender's Name 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 Lender's Address to building construction,and hereby authorize representatives of this city to enter he above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION L .,nify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature - ` Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36208016 . 00 DATE ISSUED. . . . . . . : 10/28/2009 RECEIPT #. . . . . . . . . BS000009062 REFERENCE ID # . . . : 09100197 SITE ADDRESS . . . . . : 1143 ELMSFORD DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ALEX C WU & JIANAN LIN ADDRESS . . . . . . . . . . : 1143 ELMSFORD DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4901 RECEIVED FROM . . . . : ALEX WU CONTRACTOR MIN XIE LIC # 29748 COMPANY MICHAEL SHINING CONSTRUCTION I ADDRESS 34140 AUDREY CT CITY/STATE/ZIP . . . : FREMONT, CA 94555 TELEPHONE (510) 791-1588 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 000. 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 7, 000 . 00 0 .70 0 . 00 0 .70 0 .00 1DEMOPRE SQUARE FEET 1, 924 . 00 490 . 00 0 . 00 490 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 491 . 70 0 .00 491 . 70 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 491 .70 VISA --------------- TOTAL RECEIPT 491.70 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO 9/( --, 7 CITY OF CUPERTINO DEMO %UPERTINO PERMIT APPLICATION FORM j APN1 ��z,pgl � a G D (%.DateP Building Address. 1/4 3 c CA eT�v t Y Mailing Address (if different from building address): Owner's Name: Phone:A(.Q C . G0v £. Tan4a L in ontracto - Phone : l M �chae � sh �,;�, C�nsi� �0 ge-- 63 � Fax: Contractor License #: ?q04-07 Cupertino Business License #: 2q1+2' Contact: Phonc: Fa,x: Residential Sq Footage I Q Commercial E] Sq Footage Job Description: Valuation: •-7 i Project Size: Express FaStandard Large ❑ Mjor 17 Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B ISFDWL-DELI 1DEti1OPRES Pool Demo Residential 1 B j ISFPOOL-DE.Nf _ 1 BCBSC ; Cal Bldg Standards B ALL PERUMIT ► Commission Fee ( TYPES I BSEISMICRE Seismic Residential B Revised 02r0-.'09 Community Development aim10300 Torre Avenue ✓, Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEKTINO Building Department JOB ADDRESS: PERMIT # i �+3 ck�No CA -'f 4f4f olj�4r*or OWNER'S NAME: PHONE # 6 nr±-771--Z GENERAL CONTRACTOR: FAX # rl I am not using any subcontractors: � � 1 0 o ignature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical 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 Owner/Contractor Signature Date