14050068 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10120 PENINSULA AVE CONTRACTOR:TSUEY-GUANG LIN PERMIT NO: 14050068
OWNER'S NAME: TSUEY-GUANG LIN 10120 PENINSULA AVE DATE ISSUED:05/09/2014
OWNER'S PHONE: 4082522235 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
FIRE DAMAGE REPAIR,RECONNECT GAS LINE PER
License Class Lic.# PG&E
REQUIREMENTS
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(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:$0
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:32624051 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 D F LED 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 co sued b _
with all non-point source regulations per the Cupertino Municipal Code, ction
9 18.
RE-RO
Signature Date 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.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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)
I,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 I
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 25505,25533,and 25534. !.A
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:I/!/I QQ /
permit is issued. f14
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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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 )-0/
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CU�>=R't`C t�F NO (408) 777-3228•FAX(408)777-3333•buildino(8cupertino.org `
MISC
[]PLUMING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS /, , n I APN# /
t
OW.NERNAME '� 7-2 / , PHONE
STREETADDRESS U �/ I CITY, STATE,ZIP_. �( J I FAX
CONTACT NAME / �/� PHONE 7E-KA.
STREET ADDRESS CITY,STATE,ZIP I FAX
❑ am,rR ❑ ORR.ER-BLm.DER ❑ O-AWERAGEA'T ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCr cT ❑ENGINEEK ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LLCENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHrTECT/ENGINEER NAME LICENSE T MaFR BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY I PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS TTM BLDG AN ❑YFs
BUILDING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HObffi? ❑ NO
DESCRIPTION OF WORK
t
-3 0 0 ' 0 WPM--= M.,
'10
OR
N W
TOTAL VALUATION:
k - 1100 _
By my signature below,I certify to each the following: I am the property owner or authorized agent to act on the prope owrier's f. 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. er comply with all applicable local
ordinances and state laws relating to building construction. I authorize represen Ives of Cupertino to enter the ab v -iderltified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENT IItORtTION REQUIREDMON
NOW
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ME
NIEPA1isr-4pp_M1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
7ADDRESS: 10120 peninsula ave DATE: 05/09/2014 REVIEWED BY: melissa
32624 051 BP#: *VALUATION: $0
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION
USE: p PERMIT TYPE:
woRK FIRE DAMAGE REPAIR RECONNECT GAS LINE PER PG&E REQUIREMENTS
SCOPE
u
L1c(.h. Plat Plarr ChecA Luc, 111ar(31,
,bl5, PerwilFiee.: 1,114 b. Permit pee: 1 `Lr Lr� r Fell
Onc�r;ilec'It. i s;>. Other Plumb Oth2f�1,'7(,,(, imp,
PhrniL hisp. Fee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the prelinddha information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS Lee Resolution 11-053 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: 0 Reg. ® OT0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? ®Yes (E) No $0.00
Suppl. Insp. Fee-.(j) Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
<1C,ffi?iril`'i 1"f7ti L'c'.Fee:
Work Without Permit? ® Yes 0 No $0.00 0
Advanced Planning Fee. $0.00 Select a Non-Residential 0
Building or Structure 0
Strong Motion Fee: $0.00 1.0 hrs Inspections
Bldg Stds Commission Fee: $0.00 $139.00 IST
INSP Inspection,Hourly
z�
" $0.00 $139.00 A TOTAL FEE• $139.00
Revised: 04/01/2014