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11040015 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22079 SAN FERNANDO CT CONTRACTOR:TBD--'F"E PERMIT NO: 11040015 DETER OWNER'S NAME: WILLIAM LI DATE ISSUED:04/04/2011 4ER'S PHONE: 4086490498 C CSC YL PHONE NO: ❑ LICENSED CONT .ACTPR'S DECLARATION F BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am 1 cen u der a provisions of Chapter 9 JOB DESCRIPTION: REMOVE ILLEGAL GAS LINE AT EXISTING GAS METER (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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$200 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:35712008.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION / I certify that I have read this application and state that the above information is PERMIT EXPI ORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITH DAYS OF ftRMIT 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 DA ST 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 Issued b Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. /` RE-ROOFS: Signature Date `7 l I All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. LJ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5,2 ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 n the above mentioned property for inspection purposes.(We)agree to save nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ......Ls,and expenses which may accrue against said City in consequence of the I 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 L Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Z O �' PERMIT# OWNER'S NAME: PHONE# — GENERAL CONTRACTOR: en BUSINESS LICENSE# ADDRESS: / TY/ZIPCODE: *Our municipal code requires all businesses working in the city-Vciiy-V have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME 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 kon act r Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35712008 . 00 DATE ISSUED. . . . . . . : 04/04/2011 RECEIPT # . . . . . . . . . : BS000013081 REFERENCE ID # . . . 11040015 SITE ADDRESS . . . . . : 22079 SAN FERNANDO CT SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER WILLIAM LI ADDRESS . . . . . . . . . . : 22079 SAN FERNANDO CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHUEN 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 200 . 00 1 . 00 0 . 00 1 . 00 0 .00 1BPGAS OULETS 1 . 00 63 . 00 0 . 00 63 . 00 0 . 00 1BSEISMICR VALUATION 200 . 00 0 .50 0 . 00 0 .50 0 . 00 1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 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 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 263 . 50 0 . 00 263 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 263 .50 CASH --------------- TOTAL RECEIPT 263 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO l/ � FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22079 san fernando ct DATE: 04/04/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: $200 }PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: PERMIT TYPE: WORK To Clear Code Enforcement Case: remove illegal gas line at exisitn as meter SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $63 TOTALS: $63.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.CC NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS (P'ee Resolution 09-051 1?ff ' .'I O) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $63.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes No $105.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg,Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $253.501 $0.00 TOTAL FEE: $253.50 Revised: 01/15/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• building cDcupertino.org MISC CUPERTIINO � PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS M'��& ' 3 PROJECT ADDRESS ,y OWNER NAME I PHONE /�Q /1`, E-MAIL /L _ L STREET ADDRESS ' �� CITY, STATE,ZIP ," 30/ / FAX CONTACT NAME +1 PHONE / / O ( Q IL STRE-MA EET ADDRESS CITY,STATE, ZIP 7�—�� FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT & CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAMEC/. K, �ftv ICENSE NUMBS- LICENSE TYPE BUS.LIC# COMPANY E-MAIL FAX STREET ADD gcwCITY,STATE, ] ONEVO I f3 ARCHITECT/ENGINEER NAME LICENSE NUIVIBER !/ 001 BUS.LIC A COMPANY NAME E-MAU, FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK keLn V o TOTAL VALUATION: =:RECEII/EITBY By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to omply with all applicable local ordinances and state laws relating to ilding construction. I authorize representatives of Cupertino to enter the Id feed op for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENT INF TION RE 'IRED2 09 1 Y M aWIN fiii^_•�EI3'ife !FBAeIiD3�'�., _ Es.wSW'�' .`: MEPMiscApp_2011.doc revised 03/16/11