10080072 7-
CITY OF CUPERTINO BL ILDING PERMIT
BUILDING ADDRESS: 11561 LAKE SPRING CT CONTRACTOR:BEN VALDEZ GENERAL PERMIT NO: 10080072
CONTRACTOR
WNER'S NAME: DANIEL CHEN 3401 E UAYSHORE DATE ISSUED:08/10/2010
NER'S PHONE: 4082043482 REDWC OD CITY,CA 94063 PHONE NO:(650)3464719
LICENSED CONTRACTOR'S DECLARATION
�� BUILD NG PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lic.#
Contractor � fJ � MECH r— RESIDENTIAL COMMERCIAL
Z Date !�
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB Df SCRIPTION: VELUX SKYLIGHT
(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:
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
3erfonnance of the work for which this permit is issued.
[have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft FI(or Area: Valuation:$800
lection 3700 of the Labor Code,for the performance of the work for which this
>ermit is issued. APPLICACERTIFICATION marc
APN Nun 36654023.00 Occupancy Type.
NT
P Y
certify that I have read this application and state that the above information is
orrect.I agree to comply with all city and county ordinances and state laws relating
3 building construction,and hereby authorize representatives of this city to enter PEI MIT EXPIRES IF WORK IS NOT STARTED
ipon the above mentioned property for inspection purposes. (We)agree to save WI'CHIN DAYS OF PERMIT ISSUANCE OR
ndemnify and keep harmless the City of Cupertino against liabilities,judgments,
osts,and expenses which may accrue against said City in consequence of the 180 DA OM LAST CALLED INSPECTION.
ranting of this permit. Additionally, he applicant understands and will comply
rith all non-point source regulation er the Cupertino Municipal Code,Section
Date:
h!natur Date ^/O
B LDER DECLARATION RE-ROOFS:
OWNER-
All roofs sl call be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed w thout first obtaining an inspection,I agree to remove all new materials for
ie following two reasons: inspection.
as owner of the property,or my employees with wages as their sole compensation,
ill do the work,and the structure is not intended or offered for sale(Sec.7044,
Signature of Applicant: Date:
usiness&Professions Code)
as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
nstruct the project(Sec.7044,Business&Professions Code).
rereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
clarations:
gave and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
California 3ealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
�mpensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
rformance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
ave and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
ction 3700 of the Labor Code,for the performance of the work for which this contaminar is as defined by the Bay Area Air Quality Management District I will
mit is issued. maintain cc mpliance with the Cupertino Municipal Code,Chapter 9.12 and the
utify that in the performance of the work for which this pennit is issued,I shall Health&Safety Co e,Sections 25505,25533,and 25534.
[employ any person in any manner so as to become subject to the Worker's
Ow er r a rth ent:
mpensation laws of California. If,after making this certificate of exemption,I
*me subject to the Worker's Compensation provisions of the Labor Code,I must Dat —�
thwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affil in that there is a construction lending agency for the performance of work's
for which thi 3 permit is issued(Sec.3097,Civ C.)
:rtify that I have read this application and state that the above information is Lender's Name
rect.I agree to comply with all city and county ordinances and state laws relating
ouilding construction,and hereby authorize representatives of this city to enter Lender's Address
n the above mentioned property for inspection purposes.(We)agree to save
mify and keep hannless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
iting of this permit.Additionally,the applicant understands and will comply I understand ny plans shall be used as public records.
I all non-point source regulations per the Cupertino Municipal Code,Section
3.
Licensed Prc fessional
ratur Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUIL7!7#F
VISION
DATEgs
ADDRESS:
$0
APN: BP#:
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition Repair
=APPLICATION 1GENRES
PRIMARY LLL
SFD or Duplex /.1 001. 11"L"'I
USE:
xW
00
3 �
il;•<';`t I,arl Cher/
l itrrnr>. Phar C It E k
UIr"rr["h"'
NOTE: These fees are based on the preliminary in ormation available and are onl an estimate. Contact
ntactITEMSor addn'I info.
MISC
FEE ITEMS lkg Resolution 09-051 Fff 7/1,,"09) FEE
TY/FEE
Plan Check Fee: $0.00 8 s.f. Skylight
Suppl.PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 $380.00 ISKYL<IOSF
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feer Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C'��r„sura+c:lion TO-L
A �Yes No $0.00
Acoustical Fee:
Work Without Permit? Q Yes (E) No $0.00
$0.00 Select allon-Residential
Planning Fee: Building or Structure Q
i
7`3°;:�1 ,'7:ku Y�rFtc�rtEriiclrz / E'e�t:
Strom Motion Fee:
$0.00 Select an Administrative Item
Bldg Stds Commission l=ee: $0.00
SUBTOTALS: $0.00 $380.00 TOTAL FEE: $380.00
Revised: 8/06/2010
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36654023 . 00
DATE ISSUED. . . . . . . : 08/10/2010
RECEIPT #. . . . . . . • . : BS000011146
REFERENCE ID # . . . : 10080072
SITE ADDRESS . . . . . : 11561 LAFE SPRING CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINC
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DANIEL CFEN
ADDRESS . . . . . . . . . . : 22087 SAD FEERNANDO CT
CITY/STATE/ZIP . . . : CUPERTINC , CA 95014
RECEIVED FROM . . . . : BEN VALDEZ GENL CON
CONTRACTOR . . . . . . . : BEN VALDEZ LIC # 28403
COMPANY . . . . . . . . . . : BEN VALDEZ GENERAL CONTRACTOR
ADDRESS . . . . . . . . . . : 3401 E B-z.YSHORE
CITY/STATE/ZIP . . . : REDWOOD CITY, CA 94063
TELEPHONE . . . . . . . . : (650) 346-4719
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -------- -- ---------- ---------- ----------
1BCBSC VALUATION 800 . 00 1 . 00 0 . 00 1. 00 0 .00
1SKYL<10SF EACH 1. 00 380 . 00 0 .00 380 . 00 0 .00
-------- -- ---------- ---------- ----------
TOTAL PERMIT 381 . 00 0. 00 381. 00 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ----- ---------------
CHECK 381 . 00 #1155,
---------------
TOTAL RECEIPT 381 . 00
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CITY OF
CITY OF CUPERTINO `� c' ? C)o
CUPEkTINO GENERAL BIUILDING
PERMIT APPLICY�TION FORM
APN# 6O .3 Date:
BuildinbAddress:
ManAef dffromi� Vae � l
1 A
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: xterior work only) Yes ❑ No If es,provide letter from HOA
Owner's Name: Phone #:
Contractor: y _8 �" -"
APhone. /
Fax:
Contractor License#:Lj 4 Ute'3
Cu ertino Business License#:
Contact:
\ Phone:
V"Z— Fax:
Residential Commercial
Job Description: V U x �- � L `
Building Permit Info:
' Bld Elect ❑ Plumb [] Mech ❑
Type of Construction (Usage Class): Occupancy
P Y Type:
1-A, 1-B ❑ II/IIIN-A ❑ IUIII B, IV-HT, V-B s (,�
Valuation: Square Footage:
r
Project Size: Express ❑ Standard ❑ Lar e ❑ Major ❑
Green Building: Please complete relevant portion of the Green Bu' ding/LEED Checklist& attach it
to the application or if applicable, include 7mplaset& the sheet index.
points Achieved:
Revised 07/14/09
Building Department
ELI City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
C U P E RT I N O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: N S er r PERMIT# D';bO r72
OWNER'S NAME: PHONE # 6sQ ^.3 �
GENERAL CONTRACTOR: BUSINESS LICENSE
ADDRESS: — 1CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business li nse.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONT CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
4
nature Date
Please check applicable subcontractors and c plete the following information:
✓ SUBCONTRACTOR BUSINESS NA WE BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date