10120018 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11548 COPPER SPRING CT CONTRACTOR: PERMIT NO: 10120018
OWNER'S NAME: CHAO FU-KUANG F AND LI-CHUN V -D DATE ISSUED: 12/03/2010
O"*rNER'S PHONE: 4082572704 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB r
License Class 7 Lic.# �_� � MECH r RESIDENTIAL r COMMERCIAL r
Contractor �J°, DI?l 4 Z Date
I hereby affirm that I am under the provisions of Chapter 9 JOB DESCRIPTION:REPLACING BEAM IN FRONT OF GARAGE,INCLUDE
REMAINING&REPLACING PLYWOOD&SHEETROCK
(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 Sq.Ft Floor Area: Valuation:$2200
permit is issued. <�'-WAPPLICANT CERTIFICATION APN Number:36654055.00 Occupancy Type:
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, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
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
/i
J
9.18. (' ' /I .,/�"J`--_ Dat
Signature `le �, J 1 Issued Date t/
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
I,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,
Signature of Applicant: Date:
Business&Professions Code)
I,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
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I 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
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&
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
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 Owner or authorized agent: _���
Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
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
c- and expenses which may accrue against said City in consequence of the
Jag of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
.,all non-point source regulations per the Cupertino Municipal Code,Section
1 understand my plans shall be used as public records.
9.18.
Signature Date Licensed Professional
CITY OF CUPERTINO
i
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36654055 .00
DATE ISSUED. . . . . . . : 12/03/2010
RECEIPT #. . . . . . . . . : BS000012136
REFERENCE ID # . . . : 10120018
SITE ADDRESS . . . . . : 11548 COPPER SPRING CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER CHAO FU-KUANG F AND LI-CHUN V
ADDRESS . . . . . . . . . . : 11548 COPPER SPRING CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : FU-KUANG FRANK CHAO
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------
1BCBSC VALUATION 2, 200 . 00 1 . 00 0. 00 1 .00 0 .00
1BSEISMICR VALUATION 2, 200 . 00 0 .50 0 .00 0 . 50 0 .00
1SUPINSFEE HOURS 2 . 00 252 . 00 0. 00 252 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 253 .50 0 . 00 253 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 253 .50 #464
---------------
TOTAL RECEIPT 253 .50
CITY OF CUPERTINO
CM GF
cUFE TING GENERAL BUTLLDING
PERMIT APPLICATION FORM
APN#�/ � Date: �- f
(� 12 -C3 20/()
Building Address: ,
/ �' COPPER -cpRIAVG C ouie J', �--u pcteTLNO, 6f1
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: xterior work only) Yes No If Yes, provide letter from HOA
Owner's Name: Phone#:
-LJ <Uau& SAA* CHAc ��' -25 7
Contractor: Phone:
SrAD HR/V-IC
Fax: / (�S� -,�'.57.3 ..-/�q2
Contractor License#: 872 9
Cupertino Business License#:
Contact: Phone:
Fax:
esidenttial . Commercial ❑
Job Description: l?EpCuc,`y -&40 �ee nI -in tze rit f �a1� ' ;r►�wc Q.,1�5
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
V.1-A, 1-B ❑ U/=V-A ❑ II/III B, IV-HT, V-B ❑� J
4�&
Valuation: Square Footage:
22 000
Project Size: Express dard ❑ 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:
)r help, contact Build it Green at www.builditueen.oriz
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Revised 07/14/09