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11070150 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7643 SHADOWHILL LN CONTRACTOR:THD AT-HOME PERMIT NO: 11070150 SERVICES, INC. OWNER'S NAME: LYNN CHIEN 2690 CUMBERLAND PKWY STE 301 DATE ISSUED:07/21/2011 /NER'S PHONE: 4088738888 ; ATLANTA, GA 30339-3913 PHONE NO:(510)731-1004 LICENSED CONTRACTOR'S DECLARATION f— F_ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C39 C13 Lie.# 5 3601Z i i.. c 1 ? ' MECH RESIDENTIAL COMMERCIAL Contractor "THD >�rJl Date 2. I hereby affirm that I am licensed under the proGisions of Chapter 9 JOB DESCRIPTION: RE-ROOF 27 SQUARES-TEAR OFF COMP NO RF,-SHEET INSTALL NEW COMP CLASS A (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 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:$17294 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 t APN Number:36225013.00 Occupancy"Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above inf r ation is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 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 mentioned property for inspection purposes. (We)agree to save 180 DAY M LAST CALLED INSPECTIO indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply issued by: C Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RF,-ROOFS: Signature Date Z I x/ 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. LJ R-BUILDER DECLARATION I? 2 1 t I Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVER :S T BE CLASS"A"OR BETTER 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) 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 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino 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 defined by the Bay Area Air Quality Management District performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 2553 / Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:_2/4( h�) permit is issued. 1 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 CO: RUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must 1 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 anon the above mentioned property for inspection purposes.(We)agree to save mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ,,s,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 CITY OF CUPERTINO 3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . . 36225013 . 00 DATE ISSUED. . . . . . . : 07/21/2011 RECEIPT # . . . . . . . . . : BS000014135 REFERENCE ID # . . . : 11070150 SITE ADDRESS . . . . . : 7643 SHADOWHILL LN SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . LYNN CHIEN ADDRESS . . . . . . . . . . : 7643 SHADOWHILL LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PERMIT SERVICES CONTRACTOR . . . . . . . : FRANCES BLAKE LIC # 29818 COMPANY . . . . . . . . . . : THD AT-HOME SERVICES, INC. ADDRESS . . . . . . . . . . : 2690 CUMBERLAND PKWY STE 300 CITY/STATE/ZIP . . . : ATLANTA, GA 30339-3913 TELEPHONE . . . . . . . . : (510) 731-1004 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 17, 294 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 17, 294 . 00 1 . 73 0 . 00 1 . 73 0 . 00 1REROOFRES SQ FEET 27 . 00 378 . 00 0 . 00 378 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 380 . 73 0 . 00 380 . 73 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 774 . 23 2682 --------------- TOTAL RECEIPT 774 . 23 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 309 EXTERIOR LATH 311 SCRATCH COAT 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 604 ROOF IN-PROGRESS 605 FINAL REROOF Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 L U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 776 13 5tf*D0.) PERMIT# OWNER'S NAME: Lcr4AR CHI-Clj PHONE# `ta GENERAL CONTRACTOR:-'( r BUSINESS LICENSE# ADDRESS: 'Z-4 e,6 116'2 J- L7 CITY/ZIPCODE: A/ l-6— Ab?_ *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: - � Signature Date Please check applicable subcontractors d c e e 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 le7 Owner/ ontractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 7643 Shadow Hill Lane . DATE: 07/21/2011 REVIEWED BY: RDW APN: I BP#: `VALUATION: 1$17,294 °PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Duplex PENTAMATION 1SFDWLROOF USE: P PERMIT TYPE: WORK Tear off comp, no re-sheet install new comp. SCOPE FEE ID ROOF AREA s.f. 1 REROOFFRES 2,700 F-1 Lj NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution] Is f'. ;'l.`II) FEE QTY/FEE MISC ITEMS Permit Fee: $378.00 77 Work Without Permit? 0 Yes No $0.00 A Stronjz Motion Fee: IBSEISMICR $1.73 Select an Administrative Item Bldg�Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $380.73 $0.00 TOTAL FEE: $380.73 Revised: 07/04/2011