12100221CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10397 PALO VISTA RD
OWNER'S NAME:
❑ LICENSED CONTRACTOR'S DECLARATION
ci License Class Lic. #
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.
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
permit is issued.
APPLICANT CERTIFICATION
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
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
— Er"" OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
Section 3700 of the Labor Code, for the performance of the work for which this
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
CONTRACTOR: CHANG GEORGE CHIA- PERMIT NO: 12100221
JUNG AND CHUNG SU
10102 IMPERIAL AVE DATE ISSUED: 11/28/2012
CUPERTINO, CA 95014 PHONE NO:
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB f—
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: DEMOLITION OF EXISTING RESIDENCE AND GARAGE
(2147
SQFT)
Sq. Ft Floor Area: I Valuation: $20000
APN Number: 35703027.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
.._-
Issued by, , _.-� J`" Date`-
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of Nwrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
�� I Licensed Professional
CITY OF CUPERTINO
FM-7 FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10397 Palo Vista Road
DATE: 10/31/2012
REVIEWED BY: Sean
APN:
BP#:
*VALUATION: 1$20,000
*PERMIT TYPE: Demolition Permit
PLAN C.IIEC7� T)hF,.
PRIMARY SFD or Duplex
USE:
PENTAMATION 1SFDWL-DE
PERMIT TYPE:
WORK
Demolition of existing residence and garage 2147 sq ft.
SCOPE
FEE ID FLR AREA
s.f.
1 DEMORES 2,147
A -tech, Plan Check
Plumb. Plus Check
Elec. Plan Check
bh>ch. Permit Tee:
Plnrnb, Permit Pee:
Dec. Pei -mil Fee:
other Hech. Insp,
Other Phernb hasp.
E3--L-
01her Elec. Insp.
'I'le"ch fasp. Fee:
Phnnb, hrap. rec:
Elec. Insp, Fcre:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sever District, School
District etc . These fees are based on the prelimina in ormation available and are only an estimate Contact the De t or addn'1 in o.
FEE ITEMS (Fee Resohrtion 11-053 Elf, 7/1/12j
FEE
QTY/FEE
MISC ITEMS
Plan Cheek Fee:
I
Sttppl. PC Fee.
Phimb./llfech./Elec
Permit Fee:
$534.00
Suppl, Insp. Fee:Q Reg. ® OT
rooThrs
$0.00
Plrnrrh./�ilcc:It,/Flee.
Plurrrh./rilec UE, lec Perrrrit Fee:
Construction Tine,,
Aclrninistrative Fee:
Work ['11ithout Pernritt
Advumred Plani ing Fees:
Trovel Docinnentotion Fees_
Stron); Motion Fee: IBSEISMICR
$2.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $537.001
$0.00 TOTAL FEE:
$537.00
Revised: 10/01 /2012
Rra Pacific Gas and
Electric Company'
City of Cupertino
10300 Torre Avenue
Cupertino, Ca. 95014
To Whom It May Concern:
10900 No. Blaney Avenue
Cupertino, CA 95014
SUBJECT REMOVAL. OF GAS AND / OR ELECTRIC FACILITIES
The gas and electric facilities have been removed and / or abandoned at:
w
/D 3q7 ko t 6�9&7 , 6�--A2?IK on
If you have any further questions, please contact me at (408 )725-3325
Sincerely,
Service Planning