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14030052 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20678 SHELLY DR CONTRACTOR:TBD-TO BE PERMIT NO: 14030052 DETERMINED OWNER'S NAME: CHANG WANG-YANG AND CHIANG JAN DATE ISSUED:03/07/2014 OWNER'S PHONE: 4083910605 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ �• COOPER RE-PIPE License Classn� tom—•�J 6 Lic.# �� '`'f"G 1 Contractor t tduu+ «I �;��+�J�a r�t�- Date ®3M 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. Sq.Ft Floor Area: Valuation:$6600 1 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 APN Number:35915003 00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentiripions s ction purposes. (We)agree to save 180 DAYS AST CALLED INSPECTION. indemnify and keep upertino against liabilities,judgments, costs,and expenses ainst said City in consequence of the granting of this per iapplicant understands and will comply &317AL Issued by: Dat with all non-point uthe Cupertino Municipal Code,Section9 18. �� RE-ROOFS: SignatureDate -7 +—' 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 2f 505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino M nicipal de Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)sho Id Ls ore handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I usehquiprtkf'or�A evices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the y A uality Management District I performance of the work for which this permit is issued. will maintain compliance with the l,and cipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 3 25534. Section 3700 of the Labor Code,for the performance of the work for which thisG 4 permit is issued. Owner or authorized agent: Date: -03/07//4 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9 18. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408) 777-3228•FAX(408)777-3333•building(d)cupertino.org MISC PLUMBING ❑ME LAICAL ❑ELECTRICAL ❑MISCELLAI�TEOUS PROJECT ADDRESS C 16 stip APN# sq OWNER NAME U�e T i I ct I PHONE 4 O a l O �(` E-MAIL STREET ADDRESS (r a V� O C CITY. STATE,ZIP. l I FAX kOg�bqU C( CONTACT NAME a PHONE E-MATT, STREET ADDRESS 7.3 Wo CITY,STATE,ZLPFAX .6 ❑ OWNER -❑ OANER-BUIIAER ❑ OWNER AGENT CONTRACTOR ❑CONZTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTORNAME t LICENSENUhMER� LICENSETYPEBUS.LIC;9' COMPANY NAME E-MAIL FAX �u � �• C tin STREET ADDRESS CITY,STATE,ZIP UCj� PHONE to woo� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC 4 COMPANYNAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ElSM or DUPLEX ❑ MULTI-FAMILY PROJECT IN WI DLAND ❑ YES PROJECT IN [3 YES IS THE BLDG AN ❑YES BUILDING. COMMERCIAL URBAN INTERFACE AREA � NO FLOOD ZONE ❑NO EICHLER 1101,M) ❑ NO DESCRIPTION OF WORK f . \)j trNEW TOTAL VALUATION: By my signature below,I certify to each of th Iam the property owner or authorized agent to act on the property ovmer's behalf. I have read this application and the information I have provi t. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin n. I authorize representatives of Cupertino to enter the above-identified roperty for inspection purposes. SignatureofApplicanUAgent: Date: d SUP E 1\TTAL INFORMATION REQUIRED NOW cEs �4 -��OS'ER:THECOIJit3�R ME IN __ q ��.r•= r�m.,.� Ate. � 13A KIlxY3�� MEFMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION WDDRESS: 20678 shelly dr DATE: REVIEWED BY: Mendez PN: BP#: -VALUATION: $6,600 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION 1 RPRP USE: SFD or Duplex PERMIT TYPE: WORK copper re-pipe SCOPE vi:z.tt Play,t raE.rk� Plumb.Plan Check 0.0 hrs $0.00 ='�� t' �n C:hec"', Fee: Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 hrs $47.00 01"w, P7un,h. Ins) F,"C NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef: 7/} 1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 # Plumbing Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $14.00 1PRREPIPE Re-Pipe Interior PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. ® OT o.0hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure Travel Documentation Fee: ITRAVDOC $47.00 Stron,Motion Fee: IBSEISMICR $0.66 Select an Administrative Item Bldy, Stds Commission Fee: 1BCBSC $1.00 t ® A $1TOTAL FEE: $153.66$139.66 400 Revised: 01/15/2014