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11110174Isy CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22585 SALEM AVE I ELECTRO NOR: CAMPBELL FAMILY I PERMIT NO: 11110174 OWNER'S NAME: LEE BENNY PAND TUNG JANICE Y 1352 GOLDEN LEAF cr I DATE ISSUED: II/30t2011 JWR'S PHONE: 4083662263 [ TRACY, CA 95377 1 PHONE NO: (209( 814-3874 Cr LICENSED CONTRACTOR'S DECLARATION License Class (,IU Lic. # pj1(d 16661 Contractor Date I f U 11 I hereby afflrp44 used under the provisions of Chapter 9 (commenck6Wrth 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 ofconsent 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. 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 permit is issued. PPLICANT CERTIFICATION I certify that 1 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accme 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 9.18. _ Dale t 0011 OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 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. APPLICANT CERTIFICATION I certify that 1 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 i tfy and keep harmless the City of Cupertino against liabilities, judgments, c ad expenses which may accrue against said City in consequence of the g ng of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date BUILDING PERMIT INFO: BLDG r ELECT r, PLUMB r- MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: 40 AMP RECEPTICLE OUTLET Sq. Ft Floor Area: 1 Valuation: $500 APN Number: 34212102.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM S/ /T1 CALLED INSPECTION. // Issued by: r :lei s/ Date: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. a Date: t 1 , If CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed • 6 ITEMS OF 6 • • CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34212102.00 DATE ISSUED.......: 11/30/2011 RECEIPT #.........: BS000015442 REFERENCE ID # ...: 11110174 SITE ADDRESS .....: 22585 SALEM AVE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: LEE BENNY P AND TUNG JANICE Y ADDRESS ..........: 22585 SALEM AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: JERAMEE P CAMPBELL CONTRACTOR .......: TEMPLE CAMPBELL LIC # 32988 COMPANY ..........: CAMPBELL FAMILY ELECTRIC INC ADDRESS ..........: 352 GOLDEN LEAF CT CITY/STATE/ZIP ...: TRACY, CA 95377 TELEPHONE ........: (209) 814-3874 FEE ID ---------- UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL -ADMIN ------------- HOURS ---------- 1.00 ---------- 41.00 ---------- 0.00 ---------- 41.00 ---------- 0.00 1BCBSC VALUATION 500.00 1.00 0.00 1.00 0.00 1BREMRECEP NO. OUTLETS 1.00 44.00 0.00 44.00 0.00 1BSEISMICR VALUATION 500.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT ---------- 174.50 ---------- 0.00 ---------- 174.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 174.50 --------------- 174.50 VOICE ID DESCRIPTION -------- ---------------------------- 304 ROUGH ELECTRICAL 512 FINAL HANDI-CAP REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL • '1=1 (C)F7+ ALTERNATIVE O17+ ALTERNATIVE ENERGY PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION AE 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinana.cuoertino.orn PROJECT AODRESS APNM 22-s r w, ve .OWNER NAME l.ee PHO E -MAD. r` - 2 STREET ADDRESS 22,5a5 P w, CrrY, STATE, ZIP +I C Ar I FAX CONTACT NAME_L rr ' IQ['7✓iG P ONE E-MAIL �^'Z �Q,\, r--�� yAC. V%y-� %ri%YHM I G'hj j✓NC�/fA LOM STREET ADDRESS^ P N �� . C_ 3s 2 GO l_d 1 CRY, STATE, ZIP `r, u c C /7 'iS3 -7 1 FAX ❑ OWNER ❑ OWNER -BUDDER ❑ OWNERAGENT IfCONTRACTOR ❑ CONTRACrORAGENT ❑ ARCMTE(.T ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOe NAMEI �{ LICENSE NI ER LICENSE TYPE BrIY1'C9' i/ CJ CONN��ANY NA F - II MAIL PAX I..FA IAA 2)I-icu bP v ccAcA t STREET ADDRESS n^ (, Q4I"' Com' fjTY, STATE, ZIP IrPC SSf-7 PNONE C L, c� UN / ARCHJTECT/EJGDIEER NAME LICENSE NUMBER BUS. LIC M COMPANYNAME E -MAD. FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF 6 SFD or Duplex ❑ Multi -Family PROJECT IN WI DLAND PROJECT IN STRUCTURE: ❑ Corrmercial URBAN DITERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No El SOLAR PANELS I 13/.CTRIC VEHICLE CHA RGING STATION 1 ❑ SOLAR WATER HEATING ❑ OTHER FOR SOLAR PANELS: NUAEBER OF PANELS/UNITS: KILOWATTS(COAEHERCIAL ONLY), TOTAL VALUATION: 1 DESCRIPTION OF WORK t -f0 rD a P V a -a ✓PGP1p 40 By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and State laws misting to building c cion I on a representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of ApplicanNAgent: Date: SUPPLE TION REQUIRED 1=1"`'`.v"`"; `>,'oi:aiceUSE ONLY- b'`#`l ;zt`r Ca /rl hyy A a°OVERTHEI'COUN 41''FL51 �❑<<EXPRESS�' �'�L"3�' Y kt)Y �r 1y eaavo� th z IYOd STANDAiRD,�,,,.tr 'ijt`Jtlr `]Ik ,�! �I -❑'' MAJORS.,'ii'�!�'�x-xinid,7+t4'IYi-il''� PVApp_2011.doc revised 03/16/11 17A 1* CITY OF CUPERTINO IN'/11 FEE ESTIMATOR — BUILDING DIVISION 0 i ADDRESS: 22585 salem ave DATE: 11/30/2011 REVIEWED BY: larrys UNITS APN: I BP#: "VALUATION: $500 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $44 PENTAMATION 1 REAP10 PERMIT TYPE: WORK 40 amp rete title outlet SCOPE APPLIANCE / EQUIP TYPE FEE ID Phunh. Plan Cheek QTY UNITS BP FEES I Elec. Permit Fee: IEPERMIT Recep/Switch/Outlets 1BREMRECEP Other Elec. Insp. LOJhrs $44.00 1 # $44 Paneth F'c e Suppl. Lxsp Fee PME Unit Fee: $44.00 PME Permit Fee: $44.00 Construction nix Administrative Fee: (ADMIN $41.00 Work Without Permit? Yes Q No $0.00 TOTALS: TravelDocumentation Fee: IT"VDOC $44.00 StlrongMotlon Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, school AlcMley oie 1 Theca lane are based nn the mall rdnam Information available and are on/v an estimate. Contact the Dept for addu 7lnto. FEE ITEMS (Fee Resolution 11-053 61X 7/l/11) ferry. Plan Cheek Phunh. Plan Cheek Elec. Plan Check 0.0 hrs $0.00 Gtech. Permit Fee: I'Iumb. Petnin Fee, I Elec. Permit Fee: IEPERMIT other H"Chhap. r)lher Plumb brsp.Li Other Elec. Insp. LOJhrs $44.00 Mo;:h. Insp. Fee: Plumb. hup. I'irtY rler. Insp. Fee. NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, school AlcMley oie 1 Theca lane are based nn the mall rdnam Information available and are on/v an estimate. Contact the Dept for addu 7lnto. FEE ITEMS (Fee Resolution 11-053 61X 7/l/11) FEE QTY/FEE MISC ITEMS /Flan Ch,rolc Pec: Suppl. PC I,'ee PME Plan Check: $0.00 Paneth F'c e Suppl. Lxsp Fee PME Unit Fee: $44.00 PME Permit Fee: $44.00 Construction nix Administrative Fee: (ADMIN $41.00 Work Without Permit? Yes Q No $0.00 Ad'r'mncard Planning Fees.- ees:Travel TravelDocumentation Fee: IT"VDOC $44.00 StlrongMotlon Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 ;,' , SUBTOTALS: $174.50 $0.001 TOTAL FEE: $174.50 Revised: 10/01/2011