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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21975 SAN FERNANDO AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09060072
OWNER'S NAME: ALEX TSAI DATE ISSUED: 12/04/2009
OWNER'S PHONE: 4082340286 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG[_ ELECT r- PLUMB
License Class Lic.#
MECH f— RESIDENTIAL r- COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:6"RETAINING WALL ON BACKYARD 100 FT LONG
(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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: ' Valuation:$30000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35710006.01 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued Date:(/2
Signature Date
LJ OWNER-BUILDER DECLARATION RE-ROOFS-
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,1 agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
1 have 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
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,1 shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califomia. If,after making this certificate of exemption,1 Owner or authorized a t:
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION 1 hereby affirm that there is a construction lending agency for the performance of work's
1 certify that 1 have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.1 agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
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 ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section 1 understand my plans shall be used as public records.
9.18. r,�
Licensed Professional
Signature__/ „!! `� 0 [[�� Date IL Z
CITY OF CUPERTINO
CITY OF
ICUPEkT1NO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# �Ul n,1 Date: / ' I
Building Address:
Mailing Address (if different from building address):
Owner's Name: -"S'Gq. Phone#: &e-t 0 Z �4o Z
HOA: (Exterior work only) Yes ❑ No E qof- 2 3 2- 0
q�
If yes, provide letter from HOA
Contractor: /1�-- Co h CA- Phone:
16 P Fax:
Contractor License#: -( 6 Annvuce
Cupertino Business License#:
Contact: Phone:
sGw Gt S (�v✓Pt45?-jr
Fax:
Residential Commercial ❑
Job Description:
I D D
Building Permit Info:
Bldg R Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B R
Valuation: .3 O Square Footage:
Project Size: Express ❑ Standard Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved: '��
For help, contact Build it Green at www.budditgreep.org
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEf�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1 BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3 Instal I ation/rel o cation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1 BBOILER4 Installation/relocation of ea M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP Other Electrical Inspections (per hour) E
1 MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1 MEETING 1 HR Application Meeting B
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