15110026 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21700 STEVENS CREEK BLVD CONTRACTOR:CHANG SHENG YUNG PERMIT NO:15110026
OWNER'S NAME: CHANG SHENG YUNG 1253 MICH BLUFF DR DATE ISSUED:12/16/2015 `
OWNER'S PHONE: 4086009331 SAN JOSE,CA 94087 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL
REPAINT PARKING STALLS,ACCESSIBLE PARKING,AND
License Class Lic.# (N)TRUNCATED DOME
Contractor Date
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:$2500
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 Number:35717039.00 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 mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPE TI N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the r
granting of this permit. Additionally,the applicant understands and will comply Issued by: I Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 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.
01 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
onstruct 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. I will
I 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 I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
505,25533,and 25534.
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: l� C�
permit is issued.
:yam I certify that in the performance of the work for which this permit is issued,I shall
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code,I must work's for which this permit
forthwith comply with such provisions or this permit shall be deemed revoked. t 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
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21700 STEVENS CREEK BLVD DATE: 11104120167REVIEWED BY: PHUONG
APN: 357-17-039 BP#: *VALUATION: 1$2,500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY. Civil/Religious activities PENTAMATION
Commercial Building ® Yes 1GENCOM
USE: 9 in BQ zone? �No PERMIT TYPE: � i
WORK REPAINT PARKING STALLS ACCESSIBLE PARKING AND N TRUNCATED DOME
SCOPE -
lIech. Plan Check Pizatrrl.114rrr 717eck Eke,flan Check
llech.Perrrril Fee: PhaT71).I'r:,exit 1.<e; f ec°. Permit Fee:
other llcch.,lnsp. Other•Plurnh Imp. Other Elec.INFp.—E
ileo.Irrsp. F,ee - 1'1101011.Irt}p. FeI?: Elec.Imp,Fee:
NOTE:Tkis estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees 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 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (j)No $0.00 2 hours Plan Check,Hourly
Suppl.PC Fee:. (E) Reg. 0 OT 0.0 hrs $0.00 $286.001 1STPLNCK
PME Plan Check: $0.00
Permit Fee:` $0.00
Suppl.Insp.Fee-0 Reg. Q OT 0.0 hrs $0.00
PME Unit.Fee: $0.00
PNM Permit Fee: $0.00
Construction Tax" ' , I1CONSTf1XC $0.00
Administr'trtive Fee:
Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Building or Structure 0
Trcmel L)vcurnentatibn Flees: i
Strong'Motion"Fee: IBSEISWCO $0.70 Select an Administrative Item
Bldpl Stds Commission Fee 1BCBSC $1.00 r
`*xr r .F.. TO� $287.70
Iy UBTOALS $1.70 $2 :
.�
Revised
86.00 �-
: 10/01/2015