12100089 11 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21730 STEVENS CREEK BLVD CONTRACI'M�O BE PERNITNO: 12100089
Q91Ea "FD
OWNER'S NADIE: KUEI-KAO A11NG �„� oUSG C DATE ISSUED: 10110/2012
OWNER'S PHONE: 5105797358 PHONE NO:
❑ LICENSED CONI'RACTOR'SS DECLARATION JOB DESCRIPTION: RESIDENTIAL. CONIMERCIAI.
License Class 13 Lie.N GIX d %c;Z7 2ND STORY DECK REPAIR, REMOVE LIGHT WEIGHT
�/
QQ DD CONCRETE AND REPLACE DRY ROT FRAMING LIKE FOR
Contractor to Gfl.rrLw.r U/h� Date O O Zo l LIKE
1 herebyaffirm that 1 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 fall force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
1 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:$5000
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
AI'N Number:35717091.00 Occupanry'Ir.
1p
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.1 agree to comply with all city and county ordinances and state laws relating WITHIN ISO DAYS OF PERMIT ISSUANCE OR
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and 'expenses which may accrue against said City in consequence of the /O /O,/�.
granting of this permit. Additionally,thea licani understands and will comply Issued by: t 4C Date:
with all non-point source regulations per m Cupertino Municipal Code,Section
9.18.
RP:ROOFS:
Signatu / 1 Date U 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-RUILDF.R DECLARATION
Signature of Applicant: Date:
hereby affirm that I nm exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BE'T'TER
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,m owner of the property,am exclusively contracting with licensed contractors to IIA7 ARDOIIS\IATERIAI.S 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 25505,25533,and 25534. 1 will
hereby affirm under penalty of perjury one of the falioning three maintain compliance with the Cupertina Municipal Code.Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defiled by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Muni 'pal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Code,Sections 25505.2553 , nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorizedagent: ac) (/ ZU�Date:
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 sons to become subject to the Worker's
Compensation laws of California. If,iter making this certificate of exemption,1 C NsTRIICI'ION LENDING AGENCY
become subject to the Worker's Compensation provisions of the labor Code,1 must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this pemait shall be deemed revoked work's for which this permit is issued(Sec.3097,Civ CJ
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 mid 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 l iabililies,judgments, ARCHI TEC1"S DECLARATION
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 thispemmit.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
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO _ - Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: Q U !,tC PERMIT#
OWNER'S NAME: Cunn , a tel/ PHONE #
GENERAL CONTRACTOR: L,�A 601y5—, BUSINESS LICENK#
ADDRESS: V4 0 A IqV,( CITY/ZIPCODE: 94
*Our municipal code requires all businesses working in the city to have a City of Cuperiind business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBC NTRACT RS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. o
�
1 am not using any subcontractors:
�—� Signature Date
Please check applicable subcontr ctors and c mplete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile /
Owner/ onhra•tor Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
:21 ADDRESS: 21730 Stevens Creek DATE: 10/10/2012 REVIEWED BY: Sean
A PN: BP#: 'VALUATION: $5,000
*PERMIT TYPE: Building Permit PLAN CIIECK TYPE: Alteration /Addition / Repair
PRIMARY Commercial Building PENTAMATION 1GENCOM
USE: PERMIT TYPE:
WORK Second storybalcon repair to remove light weight concrete and replace drot framinglike for like
SCOPE and replace light weight concrete and water proof membrane.
blech.Plan Check P11,111b. Plot,Cheek Flea Plan Check
blech.Permit Pei:• Plamh. Permit Fee: Elco.Permit Fee:
Other,ifech.Insp. Other Plumb Insp. Other Elce.insp.
,blech.hup. Fee: Plumb. lay.Fee: Elce.hasp.Fee:
NOTE: This estimate noes riot include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). These feav are based on lite preliminan•information available and are onh,an estimate. Contact the De t or athin'I info.
FEE ITEMS (Fee Resohttion 11-053 EB 7/1/121 FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 = hours Plan Check, Hourly
Suppl. PC Fee: Q Reg. O OT 0.0 1 hrs $0.00 $0.0()l 1
PME Plan Check: $0.00
Permit Fee: HourlyOnly? Q Yes (F) No $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 0.0 1 hrs $0.00
PML' Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tuc-
r1 dmini,strative Fee: O
Work Without Pennit? O Yes (F) No $0.00 E)
Advanced Planning Fee: $0.00 F 3 hours Inspections E)
Travel Docuntenmtion reel: $399.00 1STm'SP Inspection, Hourly
Strone Motion Fee: IBSEISMIC0 $1.05 Select an Administra0 Item
131de Stds Commission Fee: 1BCBSC $1.000
SUBTOTALS: 1 $2.051 $399.00 TOTAL. FEE: $401.05
Revised: 10/01/2012
CONSTRUCTION PERMIT APPLICATION
r' COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION oO�
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333' building8cuoertincLong \ I.
ElNEW CONSTRUCTION ❑ ADDITION / ALTERATION/TI ❑ REVISION/DEFERRED
ORIGINAL PERMIT N
PROJECT ADDRESS I��O S///4-Q VfjILS �jj//t� I APNN I / U 1
OWNERNAME J�Q fin✓ // n yPfav Prflp_ d ��[ E-MAIL
STREET ADDRESS (` TATfi21P � FAX
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CONTACT NAME PHONE E-MAIL
e e //�-ev D 579- 58 C�+r -
STREETADDRESSCITY,STATE, ZIP FAX
I v P sCr�c G<a Soy
0 OWNER ❑ OwN'ER-BUU.OER OWNER ADEM ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME / / !I LICENSE NUMBER LICENSE TYPE BUS.LIC N
(, !1 F/Zv g2
X COMPANY NAME Z G n E MA L / f FAX
II-
STREET ADDRESS /` C I PGI. CITY S A ZIP / `S3/�
ARCHITECTlENGINEERNAIAE LICENSE NUMBER ` BUS.LICK
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
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EXISTING USE PROPOSED USE CONSTA TYPE tSTO I �u
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMOTOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REAIODELAREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKRORCH AREA GARAGE AREA: DETACH
❑ATTACH
N DWELLING UNTFS: ISASECONDUNIT LJ YES SECOND STORY E]YES
BEING AD DED^. [3NO ADDITION? E]NO
PRE-APPLICATION ❑YES IFYES.PRO\'mE COPY OF ISTHEDLDGAN ❑VES— TOTAL VALUATION:
PLANNINGAPPLN ❑ AN
NO PLANNING APPROVAL LETTER EICHLER HOSIEr C]NO
By my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf, rhave read this
application and the information 1 har,F proei d i orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatine JG�i}rildi -c unction. I authorize representatives of Cupertino to enter.the above-identified property for inspection purposes.
Signature of Applicanl/Aeene �'(�// Date:
SUPPLENIE AL INF RT1ATION R QUIRED M ia'N•,c ecti ri'i a c� 3 <
•.. „r„RounNr.,sLIP�Li
_New SFD or Multif v dwellings: Apply for demolition pemiit for �',{ 1 •'i" :T;. -u--m- mm,
esisting budding(s). D oliti on permit is required prior to issuance of building V�.4 o\eR TUE-ao nTER y#yLl nulLulnarlan HF cle\v d
permit for new build lD ® E\I RLs 5 SF } CRIN
1G ILA N REVIEN
_Commercial Bld,s: Provide a completed Hazardous Materials Disclosure ❑ siiLn RD`i`1,fij ortLs � �k
form if any Hazardous Materials are being used as pan of this project. ��•t, '4
❑Y ❑ TIRE ULIT ' -F
_Copy of Plannina Approval Letter or Meeting With Planning prior to
submittal of Building Permit application. ❑� MAJox y. '.�W -TAR\ seS\�fp�e,R DISr:T
a.��N�I t�R&Icr