12050181 _ y
CITY OF CUPERTINO,BUILDING.PERMIT
BUILDING=ADDRESS: 111,52>ELMSFORD DR 'CONTRACTOR:VICTORY PERMIT NO: 12050181
CONSTRUCTION,iNC
OWNER'S NAME:. DI_NG'LI AND GU,XINYU 21812 EDEN CANYON RD DATE ISSUED:.1`.1%1672012
OWNER'S PHONE: 4085055997 CASTRO VALLEYCA .94552 PHONKNO:(510);266-5216
LICENSED CONTRACTOR',S.DECLARATION r 0
74 _ BUILDING PERMIT INFO: BLDG ELECT PLUMB
Eicense Class L-ic.#1 2.
f / MECH RESIDENTIAL COMMERCIAL-
Contractors 1!LuFi�.G�i: �, .f•�� Date. 11.. /!^ ,a�
hereby aflirmahatl sin licensed under the provisions of Chapter'9 JOB.DESCRIPTION:,CONSTROCTION OF 549 SQFT.ONE STORY ADDITIONS;,
(Ommencing,wiih Section 7600)of,Division 3 ofthe:l3usiness;A Professions REMODEL•525 SQFT,KITCHEN,AND BATH AREAS,UPGRADE
Code!and tliatimy license is in,,fu_Il force;andeffecf. MAIN ELECTRICAL PANEL TO'200AMP AND REMOVE AND,
I hereby aflirm:underpenalty,of per juryrone ofthe_followingtwo declarations:
I,have,and•will maintain a,certificate of consent`to self-insurefor Worker's
Comperisation,.as provide&for,by Section 3700 of'the,LaborCode for the
p6l1 rinance•ofthe workfor which�this.permit is:issued.
Ihave,and will maintain'Worker's'Compensation Insurance,asl,pnovidedlf6r,by
Section 3700 ofthe.Labor Code;.fo_rtheperforinance of the,work for which.this 'Sq.Ft,Floor Area: Valuation:1200000
permit is.issued:
APPLICANT'CERTIFICATION APN Number:36209015.00_ Occupancy Type:
Leeitify That I have read,thistapplication and statethat,the above information is'
correct.;1 agree to;comply wiiWall city and.county:ordihancesand,siate;laws relating
to building'construction,'and,hereby,authorize representatives-of thiscityto enter,
upomtheabove mentioned property forinspection purposes.;(We)agree;t_osave PERMIT,EXPIRES,IF WORK IS NOT STARTED
indemnnfy,and keep harmless the!Crty of Cupertmo-agamstliabilities judgments,
costs and expenses which may accrue agamst said City in consequerice_of-the WITHIN 180 DAYS OF PERIY M ISS DANCE. OR
granting ofthis permit:.Additionally,the applicanvunderstaiids and.will,coinply
1 gO.D YSFROM LAST CALLED INSPECTION.
with;all4lon=point source regulations per the Cupertino Municipal Code,Section '
9:18'. `J
'rn\V ,(Q•��^ .� /f ( Issued by: -" // `�� • Date:
Signature I- '�" "•A-4 y" ,Date 1�
❑
OWN ER=BUILDER DECLARATION
RE-ROOFS-.o
Y , P All roofs'shall,be inspected.pnor to'anyroofing;material being installed.Ifa roof is
1 hereby affirm=that I-°a►n ezem t from"ttie•Cootractor'"s;Licens`e Law,for ooe.of
the..0-10wi ijetwo reasons:, installed wiihout:firsi obtaining an inspection,I,agree to remove:.all new materials for
1,"as owner+of tlie;property;.or my'ennployees withwages as�theicsolefcompensation, ,inspection.
will,dothe work;;and the structure js;nof intend_ed,o_r offered,forsale�(Sec.70T4;
Business&:P.rofessions:Code) Signature�ofApplicant -.Date--
[,,as
Date:
l,_as owneriof the�property,,am.exclusi'vely'contracting with licensed contractors to:
construct:the.,project:(5ec:704,4,Rusiness&Pro-fessions'Code); -- --
ALL,ROOF COVERINGS TO BE`CLASS A',',OR BETTER
I'herebyaffir�mwnder penalty of perjury one o_[the+following three
declarations:,
I:ha`veand will maintain aCertificate.ofConsent;to seli4sure1or,Worker's HAZARDOUS MATERIALSiDISCLOSURE
Gompensati r!;•as provided forrby Section,3700 of,the+Labor'Code;•.fo�the; i<have'read thehazardous materials':requirem ents'under,Chapter 6.95 of the
,perform ante.ofthe work;for'which this permit is'issued. California Health&Safety.,Code,Secti6ns;25505,25533,and•25534 I will maintain
Ehave,and`will maintain Worker's'Compensation.lnsurance,as;proviiled:for'by compliance with,the.Cupertioo.Municipal Code,Chapter 9 12"and the7Health&
Section-3700 ofthe Labor Code,for the performance of the,work forwhich this Safety Code,Section 25532(a)'shoiild Istore or handle hazardous mater ial.
Additionally,should I use.equipment:ordevices which emit hazardous,aii•
perrnit is issued. contaminants.astdefined:by'_the Bay.Area Air�Quality Managem--ent District I will
(;certify that in the Performance of.the:work for which this permit is issued,I;sha11' maintaimcompliance with the Cupertino Municipal Code,Chapter 9:12 and;th'e
not�erriploy,any person<m any.manner,so"as'to become subjeefto theVorker's `Health,&&Safety'.Code;;Sectibns'.25.50.5;,25533;•and 25534.
Compensation laws - California. If iafte
r making this certificat6of exemption,
become subject to the Worker's+Compensation provisions of the•Labor.Code,I must Owner or.auth riZt=,d_ nt:-
forthwith comply;with such°provisions or;thnspermit,shalI;be fdeemed revoked ate' PV, 164 `wl 2z
APPLICANT CERTIFICATION CONSTRUCTION LENDING-AGENCY.
Itcertify that lhave read this,d06Mation.and,"state that;tWabove4niformation is I hereby affirm thaNhere ns a:construction lending agency for"the performance of work's
correct.I agree to complywith all city'and"county ordinances and sfate.'aaws relating ;for whi&h this-permrt is"issued(Sec..3097,Civ C.)
to;building,cons'truction,and'herebyauthorize,Npresent*yes of this city to enter Lender's Name
upon the above mentioned property for_inspectron,purpo_ses.(We)agree to save
indemnify and,keep;harm less=the City of:Cupcitino against liabnlrtnes,'judgments, ;L'ender'sAddress
'costs;;an'd expenses which mAYyaccGue!agaidst.aaid Ciyin'consequenmof the'
geantmg,ofthns permit.Additionalfy,"the applieant:understands andIwill comply, ARCHITECT'S`-
DECLARATION
with`all non-p6incsource regulation s'perthe Cupertino Municipal Code,Section
9:1'8., 1 understand.my plans;shall be°used,as;public records,
Signature Date; Licensed_Professional,
CITY OF"CUPERTINO BLTILDING PU_RIVIIT
BUIL DING'ADDRESS .1152 ELMS RD DRQ CONTRACTOR:VICTORY PER NO:"12050I81
CONSTRUCTION,INC ',I
OWNER'S NAME: DING LI AND GU`XINYU ' 21812-EDEN;CANYON RD ' DATE' 1SSUED 11/16%20`12, '
OWNERS PH0NE:14085055997 CASTRO VALLEY,CA 94552:` PHONE NO:(510)2,66=5216,,
JOB DESCRIPTION .RESIDENTIAL; 'COMMERCIALQ
LICENSEDCONIRACTOR'SDECLARATION
3: U.CT,ION OF,549 S FT ONE'STORY;ADDITIONS-
License Class I Lac;# '_ Q" .
^� REMM L 525'SQFT`KITCHEN AND BATH AREAS;'
Contractor.' "_ D°ate'
I`hereby affirm that I am`Iicensed under the �si,�ns of -' N ELECTRICAL"PANEL TO 200AMP AND•=REMOVE:(comme,ncing with,Sect�on',7000);of.Drvision 3of,t rofessions
Code andthat my;hcenseis,in fultforce and:effec,
i
4'/3/13-REVISION H1 CHANGE EXTERIOR-WALLON REAR SIDE
Iihereby afTrm under penalty of perjury one'of the_ owing two declarationsr
I-have.and will maintain a oertificate.of consent to selfiinsure.fo Worker's OF PROPERTY-I$SD"4%9/2013
.
Compensation,;as provided for by Section'3900 ofthe LaborCode;'for;the
performance of the work for,,which'this permit is issued; Sq.F,t.Floor Area:, Valuation:$2000.00 . _
hhaveland`will maintain Worker--Compensation lnsurance;,as provided°for by
Section 3700 of the;Labor'Code,for;the performance of the work<for'whichahis
�,. APN:Number:36209015100 Occupancy Type:
perinit'is.Issued' '
APPLICANT�CERTIFICATION"
[cerfithat Lhave'lread this application and statethat•the above information"is.
,. _ PERMIT EXPIRES IF`WORK ISNOT STARTED`
correct,I iagreeto,comply with all city and county ordinances-andistate Iaws,;relating
to building construction and hereby'authorize representatives ofthis,cityto enter' WITHIN 1'BOsDAYS OF PERMIT ISSUANCE.OR
V,01 the above mentioned property for'inspection;purpos_es (We)agree to.save '180 DAYS FROM.LAST CALLED INSPECTION.,
indemmfy.and keep harmless the CitybfCupertino against habdities judgments,. "
costs,-And,expense§jiGkh may accrue against said Cityincon§dqu6ncc•ofthe
gran`tmg of this perinrtl:Additionally the apphcant;understan&%nd`will comply Issued.by: � f'T/`I�/�/C7 Date:
WnWAll;non-poor sourc regulations per,the Cuperti Ivlumcipal Code,Section, �..
9klgl (1°ili h'�J�I ili � I -
1. T ` RE-ROOFS:
Signature; Dat eY l p11 roofs shall be,.inspectedprior to any roofigg;material beutg,inshalled: if a roof is
" ;!J' installe"d withouf.fiist,obiaining_an inspection„I agree to,renI all new inatenals fo_r:-,•
inspection.
;�I,�• •; �OWNEWBUILDER."DECLARATION" '
IFI { ' Signature of A I�cant Date'-
.
J hereby affirm tha`t'I am exempffrom 4he Contracior,sLicense.;Law_for one of PP.
the'following,two reasons Alit ROOF COVERINGS TO:BE,CLASS"A"'OR BETTER •, "
1,aslowner of the property rcor,mv employees;with,wages as their'solb,compensation, l'
,
will,do,theiwork andlthe struciure is not;intended oroffered`.forsale(Sec:704,4, I.
Busme st&Professions Code) I a l
+,
1;4sowner,of the property,lam exclusively contracting with licensed contractors to HAZARDOUS MATERIALS'DISCLOSURE
constnict+'the ro ecf Sec`7044 Business&Professions;Code).{ p 1 ( ) I have.read the hazardous matenalsregmrements under Chapter 6 95"of the
�•,l California Heal th'&+Safety-Codc,Sections 25505,25533,and�25534- I will
I:hereb affirm under penal"tyof perjury one of the following three `maintain'compliance wdit the Cu,ertino Municipal Code,jChapter 9 I3and.the+
declarations P pl�'I I a P..._
i ! a I i Health&c Safety Code,Sect]ion 25532(a)should I store"or handle hazardous;
I have and will maintain a Cert�ficate';of"Consenfto self;insure>for'Worker's material. Additional! should,!usee uimentor devices'which.em�fihazardods -
r Yr..
Compensation(as.pr6vi&d for by Section:3:700 of the Labor Code,;for;tbe air contaminants:as defined by the>Bay Area Air Quali" .Nlana emeof Distriet.I'•
.r:.. g
performance of the;work for which this permif is issued., will.maintaimcomphancewith the aper ofMumerpal-ode,:C pter 9 I21ind,
r r 05505;2553 ,.a _.25534
! d 11maintain„ Workers Compensation Insurance,as provided for.`by ty
I.have and will
the,Health&Safe Code;,Se �o
permit isFissued _. Performanceof the work for which'ths '. �3
Section j700�of'the,Laboi Code for,the
t I F Owner or authorized Date
certify that,in the,performance ofthe;work!for=which this,permrt is-'issued'I shall
r -•r'. .
+not employ any;perssonm4any-manner so as to.bccome;subject.Olhe Worker's y
e CONSTRUCTION LENDTNG,,AGENCY
Compen§ation+lawsr Cal�fom�a FIf rafter i iiingthis+certificate_of,exemption 1
become'sub�ect to the+W6& s Comp ensation.provisions,of the14h Code,'I must `I hereby affirm that theretis a construction lending agency for the:performance,of
forthwitkomply::with sucfi;provisions or this-{pe`rmit:shall be deemed_reyoked, work s fo"r whicliitfiis.permit_is,'issued(Sec.30.97 Civ,C!
Lender§'Name'
l{I AAll
PPLICANT:CERTIFICATION ,Lender's Address
- - i 1
I"certify!that I have read this a_pp hcatron and.staie that,theiabove€mfformation is i
corzectl Ilagree,to,00mply with all c�ty;andycounty ordinances and state Iawslrelating - �'I Il�o-1
_,;, to bu�ldirig constru�ct�on'land'+hereby authorize representativ-dObf tfii's city,to enter - I
7'tF-ty �,17t?WI 4IIYI 'I� H T ., i• � 1 I�.J
upon,theaboue y:foc�mspection purpose`s (W,e)agree,to Saye �
ndemmf,�dnd keep'ham ess�, a City of Cupertino against liabilities 3udgnien_ts;
ARCHITECT S DECLARATION
costs and?expensesl,.whichmay accrue"'against said City in cons 1 understand my,plan"s shall be used!as, j
grantor of this ermrtl Additionally thea licanfaunderst_ands and,Will;cothply.
with al non point source regufaI ons,,per the Cuperttna
I r ' s Mumci al'Code,,Section
,9 18 P Licensed:Professional .
;Signature" ; is l� i1�'� l , Date z
m.
I}
q�dl'
f b 11(1!1 �,. il.Id„u.l .i..,J Iil s;', I . � • ; � 'I� it '�IIUIt�jt' �l.
Z.
'CITY OF CUPERTINO
FEE,:ESThMATOR_ BUILDING DIVISION
ADDRESS:1.1'52'ELMSF:ORD DR. DATE: 0410312613' REVIEWED'BY:. MELISSA
APN: 362 09:015 BP#: - o2aSd l "`VALUATION: $0.
sPERMITTYP.E:;. Buildin:g Pe"rmit PLAN CHECK TYPE: Alteration / Repair
PRIM-ARY .P,ENTAMATION
SFD or Duplex' 1GENRES
`USE:. °PERMIT TYPE:
WORK . CHANGE EXTERIOR-WALLZONFI`GLIRAI"hOIV ON REAR'S1b;E'OF P}ROPERTY
SCOPE
itifech:F'lcan(Fiec•k °!'liao:rL�.r P-rr;;rC'he<_k •f'iec:•?'l:zr'r-('Ji�ck`
_ - Uf>:'crla.�Pa arrtrCF.i�>.: l wij..-41r>r:u 1-ec:- 1 1Le:-Pc,nut l e>c:
LCJt! rt,Ale.&h.Insp, Oriler.1?hofib,i sj:: C i't`.cr-f'lt:,'1?up,
1:Iech.insp.-Pe'es ph47 1�, 1 iso. G';-.r: Eie nspl IL"re
NOTE:.'This•eslimate:does=not indude fees�du_e to other Departments'(i:e.Pldnnhzk,.Public:Works;.Fite,San taryySewer District,Sehool
District;,eta), These,eekare 6assed�dh4he; -relimin'a'.'in ormationlavailahle,and'are�ohi anestiinkte:' Contactlhe De tjonaddn!n o.
FEE ITEMS,(Fee Resolution,11-65.4 GE(''7/1112), FEE QTY/FEE MISC.ITEMS
Plan Check Fee: Hourly Only? Yes 'No $0.00: hours' Plan Check,Hourly
Suppl. PC F.ee:. .Reg. :Q..OT 0;0 firs $0:00 $266.00- .1STPLNCK!
PIGIE.Plan Check: $0.00 }.
Permit Fee:. $0.0.0
Supp1:,Irisp: Fee; ;Reg: Q QT Q;`Q» hrs $0.00
PMFUri_t Fee:: $0:00
PMP:Permit Fee:. $0'00'
Conso,wchon ja-v: _T
Work'Without>PermiO 0`Yes: No $0.00
-Advanced Ndhniri"".Eee $0.00 Select a Non.-Residential ,
Building,or Structure
Traf=el Doc:rrincntutic�ra"'!'ees:
-�Sfrong:lVlotion Fee-, $0.00 m',Select an.Admiristrative Item
-
`Bld'p S'tdsi.Cominission Fee: $.0:00.
m
$266.00
F ,? suB; oTA�I:s $0.00 I ToAL FEE 2
$ 66.00
._ ,
Revised: 04(01%2013 6 '
CITY OF CUPERTIN.O BUILDING PERMIT
BUII,DI_NG ADDRESS; 11'52 ELMSFORD DR CONTRACTOR:VICTORY PERMITNO: 12010181,
CONS7T2UCTION,INC
OW,NEWS-NAME: DING U AND`GU XiNYU 21812,EDEN,CANYONRD DATE ISSUED: 1]/16/2012
OWNER'S.PHONE: 408505.5997' CAST RO:VALLEY,CA, 2,4553 PHONE N0:.(510j 26&5216
❑ LICENSED�CONTRACTOR'S DECLARATION" � � �-
BUILDING'PERMIT INFO:- BLDG-' ELECT' PLUMB
License Class Lic.#
MECH'F RESIDENTIAL,:f COMMERCIAL t—
Contractor Date
hereby•_affirmjhaf ham licensed undef'the provisions of'Chapter.9 JOB DESCRIPTION;CONSTRUC'rlON'OF 549•SQFf ONE S'fORY ADDIT.IONS:
(coin riiencing,-rvitfi Section 7000)of Division;3'of'the Business,Sc Professions REMODEL 525 SQFT KITCHEN AND BATH,AREA'S,UPGRADE
`Code and,that'iny license Win full force and effect: MAIN.ELECTRICAL,P,ANEL TO 200AMP.AND REMbVE;ATJt)
_.
`1;22/13 REVISION tl.I-CHANGE'TO SHEAR WALL ISSD•I"/22!1`3
.Ih
hereby affirm',under,penalty of perjury one ofthe following,tvvo declarations I/22/201'3 DEPERRE.DkI'JRUSS'CALCS ISSD 1/22/13
1 ,
have an&will maintaina certificate of consent to:self-insuresfor*biker's
Compensation„as provided`for,bySection 3700 of the LaborCode,for the =
performance_of the work�forwhich this,perrnit:is�i'ssucd.
l have and wi11 maintain W.orker's,,Compensation Insurance,as,provided:for by Sq.Ft Floor.Area: Valuation:$200000
,Section 37
'go Labor Code;for the performanecofthe`work for Which this
perinitrs,issued.,
APN Number:36209015.00 Occupancy Type:
APPLICANT'CERTIFICATION. _
I certify that,f,have:read�tliis;application and state`that the'above'information is
corrcct.,Jiagree'to comply'whh all city and county ordinances and sta_te'laws relating
to building construction,and;hereliy authorize rcpresentatiyes ofthis city to enter” PERMIT.EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for'inspeUion=purposes'. (We)agnc tosave =
indemnify and keep harmless the Cit ol�Cuperhho against liabihties,:judgments, WITHIN 180 DAYS .OF PERMIT ISSUANCE OR
costs and expenses which may-accrue against said City'inkconscquenceof",the
gran4ng oP,[his.pc�mi[. Additionally,the applicant.,understands?and will comply 18O'DAYS FROM,LAST ,CALLED*INSPECTION.
witb:all non-point source�regulati"ons_per the;,Cupertino Municipal Code,Section
9'18. Issued,by: Dater•
Signature Date
❑ OWNER-BUILDER,DF,CLARATION RE--ROOFS:
All roofs shall be inspected:prior to any roofing-material beiligamstalled..lf`a,roof'is
'1 hereby,affirm that)am,ezempt;from the Contractor;'-s LicenseLaw'for one of 'installed without first obtaining an-'inspecuon,,l agree to Fcilovc all.new materials*for
the follbWingttwo,reasons: inspection:
Las owner°of tfie'.properly,or,my employees with wages,•a-s,tlicir sole,compensation,
will do the work„and the structure is not,intcnde&or_+offe_red-for-sale(Sce.70,44„ Signature o Applicant: Da(c:,
'Business&PFofessions Code) „
,I„as.owner-of the property,am exclusively contracting with licensed,contractors to
•construct the project(Scc.7044,Business,&Professions,Code). ALL ROOF_COVERINCS”1'O'BE CLASS"A”OR BETI:ER
I hereby'affirm under'penalty of perjury one of the followiill g^three,
ifecIarati,ous:, IIA7ARDOUS'MATERIAIS DISCLOSURE.
.l h"avc and will maintain a'Certificate of Consent,'fo�self-insure for Worker's I hay.e,read,the hazardous,materials,requirements,uoder Chapter 6.95 ofthe
Compensation,-as provided for by,Section 37Zof"tlie,Labor:Codc„for'the California 11calth&SafetyaCode,Sections 25505,25533;'and 25534. twill maintain
Performance of the;woik forwhichMis,permit is=issued, coin Pha- wi
rice tli,the Cupertino,Nlunicipal Code,Chapter 9.12.and the Health K
I have andlw—l]I maintain Wotkcr's Coinpensafion'insurance,as provided,forby Safety-Code,Section 25532(a)should 1 store or handle hazardous materiai..
Section,3760 of the:C abor Code,for the performance of the'work for which this Additionally,should I use equipment or_devices WhMremithaza�dous air
permit is issued. contaminants as defined.by the Bav Ae6a Air'Quality Managemcnt;District l'Nill
maintain,comphance with,the,Cupertino,Nlunicipal Code;Chapter 9.12 and the
I certify ihat'in`ihe'performanceygf the work fo-r.�which this permit�i's issued,khall� Health&Safety"Code;�Se.ctions,25505,2553.3,;;and 25-534,
notemployany persoif to any,mAmier,'so as;:to become subject to the'W,orker's
Compensation laws of California: If,,aftcrmaking thi's ceriificate•of exemption,I Owner or authorized agent:
beeome subject"to tH Worker s:Conipcn'sation provisions of the Labor,Codes I must" Date:
forthwith'corq ly,with,such provisions or,this'permit shallbe deemed'revoked.
CON'S'FRUCI'ION'LE:NDIN'G AGENCY.
APPLICANT CERTIFICATION llhercbyaftirm that there is,,a construction,lending agency'.for the performance ofwoik'.s
Lcerti.fy that I have read this app!ication;andtstate,that'the above information;§ for.which this permit is issued(Sec 30 9,7,,Civ,C.)
correct,I agreeto,comply with all-city and,.c_ounty'ordinances'andkstate,laws;rclatingt Lender's Nme
to:building�constructioii,aifd hereby autliorize;representaiives of,tliis city to enter
upon°the zibove'mcntioned property for inspection purposes;;(:We)agree to save` l e`ndcr's Address
"inderinily'and keep"harmless the City ol'Cupertmo against'liabilities,.lud'gi5ients,
costs,and expenses which may accrue against said,:Cif in con-S&uence'ofthe
granling;of this permit:Additionally th&applicant undefsffnds and will.comply ARCHITECT'S DECLARATION
with all non-point_+source regula[ions,per'the Cupciti'no,ivlunicipal Code,SectionI understand my'plans shall be used';as public records:
9:18:
,Licensed Professional-
Sig"naturc Date
CITY G' CUPE•RTI_N:O
FEE_ESTIMATOR_,BUILDING DIVISION
ADDRESS 1152 ELM9FQRD;DR, DATE:' REVIEWED BY:
AM` EifW- 1`2.505181 'VALUATION: $0'
PERMIT TYPE%. Building'Permit PLAN CHECK TYPE: Alteration / Repair.
TIMMA'RY:' �PENTAMAT.ION
SFD or Duplex 1GENRES
,USE: ;PE-RMIT TYPE: a
WORK' ,REVISLON'#1-'CH'ANGE.TO'SHEAR WALL - DErERRE5#2 NEIN' TRUSS CALLS
SCOPE,_.
WLEMe
NEI
P C r _a �„MIS
. tl'� w _ t -' '�
Lfeclr:Plan Ciec•k' Pbudb: Plun Cr ec'n" 1shc:: Plan,Check
.:Llec7i Peemi[F&2,- urrzh. Per n-iil A/oe,•:Permit Fee:
nther,hlec;fr•/nsp; C)�hfi T1r rnFi lns/. Li Orh`er !'ler.lnsr.
A%/.,eh. /nsp. /`iz : Fke. Eicc.,In.w. Fee:,
'NO,TE:This es'timdte doeS.'not.anclude,fees dice to-other Departments(4e.Plann'ing;,Public Worki,.Fire,.San"itarySewer,District;Sehool
District,•eh . These ees are based�on'Ith-e,-relimina $n"ormdtion-,available+and'aze onl an.estimate Contact the A? t oraddWTin o.
FEE':ITEMS...
Fee'.Resolution.Ll-053,G{f-7/1;!10 FEEQTY/FEE MISC ITEMS
'Plan Check•Fee' 'Hourly,Only? 0 Ves (F)'No .$0.00 hours Ndn Check,Hourly
=Supp.].'.,PC Feer C-)`Reg•. Q OT 0,.0 hrs $0.00 $266:00 STPLNC
PME Plan.Check:'. $0_.00
Permit Fee:.:.- $0.001
Supp] Insp.Fee:Q Reg: Q OT 0 0 hrs $0.00
F
Unit it e
- e.," $0:00
PME Perm t F,ee: $0.00
Cbnslrzicficln
�1
di.
nirrislraCi;L'c'
0
Work,VJitliout Permit?, Yes No- ': $0.00'
Advanced,Plannin Fee: $0:00 Selectaa Non-Residential Q
7'i urc l L_)c>c�.iirinti�l.ic�re F'ses": Buildi"rig or.Structure
Strom Motion Fee: $0.00 0 # Revisions
Bldg Stds Coniifrission Fee:
• $0:00 $0-00 ?,RE,YSFDWL SFDwi;
SU'B I QTALS $0.00, ;$266Q0 TOIL FE> $266.00
t . ,. �b
Revised: 16101/20,12
CITY OF CUPERTINO BUILDING .PERMIT
Bl7lLDING,ADDRESS 11'52'ELMSFORD DR. CONTRACTOR:;VICI;OR_Y PER�II"I'NO: 120501'f31
CONSTRUCTION;INC
OWNERS NAME: DING LI AND GO XIN=YU, 2I'S 12TIAN CANYON RD, DATE ISSUED-1 111612012
;OPV-NER!S_ PI10NEc 4085055997 CA'STRO VALLEY,�CA 94552 PHONE NO,:(510)266-1216
LICENSED CONTRACTORS DECLA'RAiI`IONI— 7
BUILDING PERMIT INFO, BLDG. � ELECT� PLUMB
I:licenseClass Lic.:#'
MECH RESIDENTIAL r COMMERCIAL
Contractor Date
I;hereby affirm that I am;licensed:under.the provisions of+Chapter•9 JOB DESCRIPTION_!CONSTRUCTION OF 549 SQFT`ONE:STORY ADDI;I'IONS,
REMODEL 525 SQFYKITCHEN'AND BATH AREAS,UPGRADE
(` ,mmencin gw,Nth' (.Division 3 of the Business;&Professions MAIN ELECTRICAL P.ANEL'TO.200AMP AND REMOVE AND
coSeetion:70,00)0
Code and that my license,is m,'full;forceiand'effect.
I:hereby affirm Lfhder`penalty of perjury one ofthe following two declarations:
I have and will maintain a certificate;of'con"sent to self-insureijor Worker's
�Compehsation,;as provided for'bySection 3700 ofthe,LaborCode,.for the;
performance of the work'for which.this;permit is'issued,
I have and will maintain Worker's,Compensation"lnsurance,as.provided for by
S'e iion 3:700,of the Labor Code.:f6r'the performance-ofthe work forwhich this Sq.Et Floor Arca: Valuation:$200000
,permit;is issued:
APPLICANT'CERTIFICATION AP.N'.Number,:4620901500 Occupancy"Fype:
Iscertify,that I have read this app hcauomand;-state thatahe above information,is
'correct.I agree to:comply with all city;and°county ordinances andsstate lawsirelatin_g
to building,construction,and hereby authorize,representatives,oftfil`'city°to enter
upon.the;aboye'amentioned property for inspection purposes. (We),agrcc,to save PERMIT EXPIRES IF WORK IS NOT STARTED
•indemnify"and,keep harmlessthe City.of-Cupertino against liabdities,.judgments,
,Costs,,and,expenses which;mayIaccru6againsrsaid City In consequence of--the, 'WITH_IN I$0 DAYS OF PERMIT ISSUANCE OR,
granting oflhis permit: Additionally,the:applicaneunderstaiids and will comply 180 DAYS FROM LAST CALLED INSPECTION.with.al1,non-point;source;regulations pertheaCupeitino Municipal Code,_Section
9.1,9.
Signature ,Date; Issued by:�` Dafe:
❑ OWNER-BUILDER DECLARATION, +
RE-ROOFS:,
''I'tierebyaffrm that Lam exempt from the,Cohtractor's',License Law for one,ofAll;rooFs shall be inspected prior to anyroofing material being installed. Ifa,roof is.
the following two reasons: installed;wit-hout first obtaining-an'inspection, I agree'twrem_ove all new materials for
,J,as,owner of the 6peiTy;or myemployees with wages as.their"sole compensation, '.i'nspection:
'will_do the work,and the structure,is notiutended or offered'-for sale(Sec"7044, -
.I3u"siness.&°Professions+Code), Signature of,Applicant: Date:
`.I;as ownerof the:property;`a n.ezclusivcly contracting,.with licensed,contractors to
•construcCthe project,,(Sec.7044,Business&Professions Code)..
ALL ROOF COVERINGS TO'�BE CLASS",A"O.R,BET-7'ER
1 hereby affirm Odder penalty°of perjur,,.yone.of,thefollowing'Jiree -
iheclarations:.
1'haveYan&will inamtani7a,Certrficate of:Consent to self-insure for Workei's HAZARDOUS MATERIALS.UISCLOSURE
Coinpensation;as provided,for,by"S'ection 37.00 of the Labor.Code,for the •I"have read the:hazardous materials requirements under Chapter,O 9 of the
performancerof'the work:for whl h,thi's permit is issued. California health&'Safety Code,Sections.25505 25533;,,and 25534. I;will mainlaig
lhzvewid'will inaintain,Woik,e,r,:s Compensation lnsurance,;as provided Tor:by compliance with,the Cupertino Municipal Code, chapter:9r12and the licalth&
.Section 37.0-0.of,the.Labor',Code,for lhe,perforrnance ofthe workNforwh`ich°this Safety Code,Section 25532(a)should I store or handle_hazardous material;
Additionally should Lse uequipmenro"r devices which,emit,hazardous air
permit is issued. _
contanii'nants astdcfined by,the_Bay A,rea,Air+Quality Managemenfbistnct Pwill
I'certi,fyahat in the performance of the woik for which thi's permit is issued;,I sha-II maintaiW'complianccrwith'the Cupertino Municipal Code,,,Cha,ptee 9:f-2-and the
not.employ any person'in any rnanner,so as,to become subject to the'IW,orkef,'s Health&Safety Godc„Sections 25505,'25533,and 255.34.
Compensation laws ofCAlifornia.. If„after'making tliis cerlificate�ofexemption,•I
become sobje,t to the Worke-,'s�C.ompensation=provisions of,the,Labor Code,I'must Owner or authorized agent:
fofthwith�compl'y with such provisions or'this peririit�sha-II be;8ecmed;revo,ked, Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify ihat.l•.have rea&this application and state'that the•above°information is' I hereby,affir4iithafthe're is a construction lending agency for the performance of'work's,
correct.`I agree,to comply wi[I%all cityand'county°ordinances and sta[c�laws relating for which this,perinit'i° issued(Sec.3097:,Ci'wC')
to building con struction,!and'dhtrebytauthoiize representatives of-this city iwenter Lender's Name
upon the'abov,e menfioned,property,for`inspection=purposes,.,(We)agree io{save;
indemnify and keep,harmless::tlie4City of Cupertino against liabilities,'ju_dgments,. `Leader;,,Address,
°costs,and expenses which may accrue against said.City in coinsequence,of the
*aming,ofthis penni[ Additionally;„the applicant understands and will comply
,with all non-pointsource regulations:perthe CuPerti'no Municipal Code;Section ARCHI'f.EC"I'S DECLAR:\'1lON
9.18. kunders,tand my plans sha11 be used as public,records.
:Si'gnaturc Date Licensed Professional
CITY OF`CUPERTINO
FEE ENTIMAT.OR BUILD:IN:GDIVISION
ADDRESS: 1452 Elmsford Dr DATE: '05%/M2,01-2. REVIEWED BY: Sean,
V 11
APN: BP#: ��, Q � � VALUATION: 1$200,000
*PERMIT.TYPE: Building Permit PLAN CHECKTVPE: Addition
PRIMARY, 2nd Unit? 0 Yes ° No PE_NTAMATION
S.FD or Duplex ? 1R3SFDADD
USE:, OTC. Oyes ONo PERMIT'TYPE:
WORK 'Construct a 549.s -ft,one story of additions remodel 392 sq ft upgrade main electftaf panel to 2,00
SCOPE, amp, reiriov.e and replace the furnace'.
TYPE OF FLR.AREA
OCCUPANCY TYPE': CONSTR. s.f. PCFEE:S PC FEE ID. BPFEES BP FEE ID
R=3 (Custom) 11-13,111-13 549 54,9 $2,420:OG 1R3PLNCK $1,519.00. 1R31NSP
TOTALS: 549
s 0
, ' ,
� ,� 221,
MECI3 HO ; I.Y �4 No rPI.UMB,H®URIY0 Yeses QiNo_ EI.EC,HO;ITRTJY O Yes No
'Meeh.Plan Check 0:0 hrs; $0.00 .Plm„`!). P!ur Elec. Plan'Check 0.0 hrs. $0.00
ch.PermitF.,ee 1MPE12MIT F'!iirr:i..Pt nir 9 r': EleC...P
Nleermit Fee: lEPERMIT
Other Mech. Insp. Q,.O' hrs $44::00. C)1,,''iEr P1r �1 n.rla: Other,Elec.Insp. 0:0' �hrs $44.00
,Lech.hvvi ./�-�< 6— . r �;. ?:E e: l ierc'..Irs,+.
- �.r,u:r�), W .e:
NATE.This estiirfate.d es.not includl fee's.due-io oiher Departmenis(Le:Planning;.Piiblie Works,Fire,.Sanitary-Sewer District,,SchooL
District;etc. . These.'ees are based on,the relimin4,irif orination available aitd.'are onl"pan esiiftidm., ;Contact the De t. or addn.74n o.
FEE ITEMS(Fee Resdluiie)n 1,1=033 Eff"7II/.111 . FEE QTY/FEE MJSC:ITEM&
Plan Check-Fee: .$-2,420.0.0 392' s:f. Remodel,Other,
Suppl. PC Fee: O Reg. OT 0..,0 : hrs: $0.00 $457:00 7,REMRESOTH
PME Plan Check: $0.00. 1 # Mechanical
Permit Feer $1.,519:00 $1 a0.00 IMFR=<l00 Furnace,Forced-Air
Suppl: Imp. Fee O Reg. :O OT p`p hrs $0.00 200 amps Electrical
PME Unit Fee: $0..00 $44,00 ]ERT<200 S.etvices'
PME Permit Fee: $88.00
T-r
Co1stlr.tcti�n7'zr�:
rl.ritnt.f2strrati l e,li t;- 0
Work Without;Permit? Oyes O No $0.00 G
Advanced Kanni2 Fee PLLONGRNGR $7-1.37 Select,a_Non-Residential l
Travel Documentation Fee: 1TRAVD07 $44:.00
Building-or Structure 0
Strong Motion Feer. I.&EISMICR $20,.00 Select an Administ'rafive'Ifem
131d�Stds'Cominiss`ion'F'ee'--. 1BCBSC $8.00
.. S TALS $4,170.3T $6.31:00Y,.., �o � FEE $44,80,1.37
Revised: 05/0172012