15040022 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10721 JOHANSEN DR CONTRACTOR:QUIROZ PERMIT NO: 15040022
CONSTRUCTION INC
OWNER'S NAME: YAO TODD T AND LANHUA G 105 N 27TH ST DATE ISSUED:04/03/2015
OWNER'S PHONE: 4086560929 SAN JOSE,CA 95116 PHONE NO:(408)999-0881
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E]4 L INSTALL GAS LINE FOR KITCHEN STOVE TOP
License Class Lic.# l
Contractor&UU1 Co_t3 Y JA('7C*—Date Y—'9—tS
I hereby affirm that I aro 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:$900
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:37537067.00 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 CALLED INSPECTION.
indemnify and keep harmless the City of Cu rtmo against liabilities,judgments,
costs,and expenses which may accrue agai st aid City in consequence of the
granting of this permit. Additionally,the pli t understands and will comply Issued by: Date: 1 j
with all non oint source regul ti ns per Cu a 'no Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date "S �� 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
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
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 Q lity Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cup tino M i i at Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 255 ,2553 , 534.
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
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
isGENERAL PERMIT APPLICATION ti� MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �(�
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ( ,
CUPERTINt (408)777-3228•FAX(408)777-3333•building
(a)cupertino.ora �v MISC
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRES' APT"
OWNER NAMEu 04_jPHONE j` �` E-MAIL u 4
STREET ADDRESS __ Q CITY,STATE,,ZIP �b^ FAX
/.1 f f n
CONTACT NAME O PHONE, ( ^o np' T-0�� U l�Z.'� w
STREET ADDRESS �dY�fi� 1^ CITY, ZIP �( J��S�jCI� s� FAX�n� Rqq-�gZ
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT'1 CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAMEn , Z�C VN LICENSE NUMBER no l LICENSE TYPE � BUS.LIC#
COMPANY NAME 0 Z (�_ _ u (�J E MAIL.. t�ro2 I.tlo'C FAX L IR q q-OSS Z
STREET ADDRESS iv 10 qr`fi� y�fLj C31W,r CITY,STATE,ZIP �TJI1� (?57,� PHONE
ARCHITECT/ENGINEERNAME 1 , LICENSENUMBER `IV �1 BUS.LIC 1 l
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SET)or DUPLEX ❑ MULTI-FAMII,Y PROTECT IN WILDLAND ❑ YES PROJECT IN EI YES IS THE BLDG AN El YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
s (O lvi crc VAa.,_j -gypcNp s `h-e fir c
TOTAL VALUATION: a) RECE VED B
.....s
By my signature below,I certify to each of the followingam the property e o authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correc. have read a De crip of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to lding construc authorize res s of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
S1 JPPT FMENTtL INFORMATION REQUIREDAP
It OFFICE-USE ONL7%,
w EJ OVER-THE COUNTER
� C7 EXPRESS ����6
v a�_
LARGE
K--,
OR.
OR
MEPMiscApp_2011.doc revised 06/21/11
1 '
n�
--J, J� CITY OF CUPERTINO
F ESTIMATOR-BUILDING DIVISION
7ADD. SS: 10271 ' hnson ave DATE: 04/03/2015 REVIEWED BY: Mendez
BP#: *VALUATION: $g00
xPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD Or Duplex PENTAMATION 1 RPGAS
USE: PERMIT TYPE:
WORK �installqas line for kitchen stove to
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1POASRES 1 # $72
TOTALS: $72.00
.:
w _
l9c�c/,, Plan E'hEzc.k Plumb.Plan Check 0.0 hrs $0.00 Elec. Plan(`hick
6lech. Permit Five: Plumb,Permit Fee: IPPERMIT G&c. /' retia t`cf
(hher Alech. 7risn, Other Plumb Insp. 0.0 hrs 1 $48.00 Othert:-lec.Insp.
Llech. hzsh. Fee: I F'hmtb. hasp. Fee: LZec.Imp. F2?e:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E('. 7/f 1113) FEE QTY/FEE MISC ITEMS
111an Check Fee:
suppl. P(:'Pk(,'
PME Plan Check: $0.00
Per•inil Fee:
su gip/, R/s/?I7 c e
PME Unit Fee: $72.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: 1ADMIN $45.00
Work Without Permit? ® Yes (j) No $0.00
Advomeed Pkunning Fees:
Travel Documentation Fee: ITRA VDOC $48.00 i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC. $1.00
� $214.50 $0.00 3,
TOS AL FEE: $214.50
�
Revised: 02/14/2015