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10090020CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18791 ARATA WAY CONTRACTOR: CHI -HUNG SHEK PERMIT NO: 10090020 OWNER'S NAME: CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r r— r— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # MECH r— RESIDENTIAL r COMMERCIAL r Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADDITION OF 600 SQ FT TO BEDRM, FAMILY AND BATH (commencing with Section 7000) of Division 3 of the Business & Professions ROOM Code and that my license is in full force and effect. PERMIT #16271 INCORPORATED FROM SANTA CLARA 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: $100 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 37512028.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Issued Date: � Signature Date OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: 1, as owner of the property, am exclusively contracting with licensed conM to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. 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 : APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address 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 regulati s per the Cupertino Municipal Code, Section 9.18. V I understand my plans shall be used as public records. Signature Da' ` ( Licensed Professional CITY OF CUPERTINO rm-7 FEE ESTIMATOR — BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: 'VALUATION: $100 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: OVER THE COUNTER. O Yes O No PENTAMATION 1 R3SFDADD PERMIT TYPE: WORK SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 i $0.00 MECH, HOURLY O Yes G No PLUMB, HDLRLY C)Yes O No ELEC, HOURLY O Yes (F)No Much. Plan Check Plumb, Moo C he(. Elec, Plon ChGcck FT FL1eclrPermit Fee: Phimb. Permit Fee: Glee. Permir lice: Other .tlech. Insp Other Mimi) In.rp.LJ 01her Elec. Insp.Li Afoch. Gup. Fete. Plumb. hi.�p. F'l-c. flee. Imp. P' e. NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (F'ee Resolution 09-051 E . 711110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: O Reg. O OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee10 Reg. © OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consiritction Tax Acoustical Fee: O Yes (E) No $0.00 O 0 Work Without Permit? O Yes O No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure O i Travel Doumnentution Fees: Strong, Motion Fee: IBSEISMICR $0.50 4.0 hrs $504..00 Standard Hourly Rate Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $1.50 $504,00 TOTAL FEE: 1 $505.50 Revised: 9/01 /2010