10080155 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21424 SHANNON CT CONTWF CTOR:SHENG'S CONSTRUCTION PERMIT NO:10080155
INC
!VNER'S NAME: WENSON WONG 10078 SANTA CLARA AVE DATE ISSUED:08/23/2010
NNER'S PHONE: 4088874955 CUPER7 INO,CA 95014 PHONE NO:(415)519-7874
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT I— PLUMB
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL r
Contractor v Date '�
I hereby affirm that I am Inc sed under the provisions of Cha ter 9 JOB DI!SCRIPTION:REMOVE&FILL IN EXISTING POOL(165 SQ)
(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 FI nor Area: Valuation:$5000
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
APN Nu nber:36202023.00 Occupancy Type:
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 PE RMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 1811 DAYS FROM LAST CALLED INSPECTION.
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 Issued by: Date:
9.18.
c:rtnatu��J _Date
V RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspectic n.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signatur:of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additio pally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contain nants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health &Safety Code,Sections 25505,25533,and 25534.
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 Owner ur authorized agen
Compensation laws of Califomia. If,after making this certificate of exemption,I Date: z J
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for whi(.h this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
the above mentioned property for inspection purposes.(We)agree to save
.unify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I under..tand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date (�
CITY OF CUPEPTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot::
APN . . . . . . . . : 3620202:3 .00
DATE ISSUED. . . . . . . : 08/23/2010
RECEIPT #. . . . . . . . . BS00001:_247
REFERENCE ID # . . . : 1008015!3
SITE ADDRESS . . . . . : 21424 S:3ANNON CT
SUBDIVISION . . . . . .
CITY CUPERT I:JO
IMPACT AREA . . . . . .
OWNER WENSON TONG
ADDRESS . . . . . . . . . . : 21424 S3ANNON CT
CITY/STATE/ZIP . . . : CUPERTIiO, CA 95014
RECEIVED FROM . . . . : WENSON GONG
CONTRACTOR SHENG J YONG LIC # 25890
COMPANY SHENG'S CONSTRUCTION INC
ADDRESS 10078 SANTA CLARA AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (415) 519-7874
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 000 . 00 1 .00 0 .00 1. 00 0 .00
1BSEISMICR VALUATION 5, 000. 00 0 .50 0 .00 0. 50 0 .00
1DEMOPRE EACH 1. 00 291 .00 0 .00 291. 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 292 .50 0 .00 292 .50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 292 .50 #lC6
---------------
TOTAL RECEIPT 292 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ---------------------
704 DEMO
CITY OF CUPERTINO
DEMO
CITY
E T
CU 1�,1NO PERMIT APPLICATION FORM
Date:
Z
Building Address:
I i � J�
Mailing Address ( f different from building address):
hone:
Owner's Name:
Phone
Contractor:
_ Fax:
Contractor License #:
Cu ertino Business License#: 2 Phone: ,
Contact:
Fax:
Residential ❑ Sq Footage
Commercial ❑ Sq Footage
Job Description:
Valuation:
Project Size: Express ❑ Standard ❑ Large ❑j Major ❑
Please complete relevant portions of the Green Bui[ding Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Resider.tial B 1SFDWL-DEM
7 ------ ; - 7
1DEMOPRES Pool Demo Residential B 1SFPOOL-DOW
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Resid-ntial B
Revised 01/07/09