12010078 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20699 RODRIGUES AVE CONTRACTOR:AC LIU CONSTRUCTION, PERMIT NO: 12010078
INC
OWNER'S NAME: AC&D LIU INVESTMENTS LLC 1585 WESSEX AVE DATE ISSUED:01/10/2012
OWNER'S PHONE: 6504920857 LOS ALTOS,CA 94024 PHONE NO:(650)492-0857
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# "/(96 �
MECH r- RESIDENTIAL� COMMERCIAL�
Contractor l�'� CUKS � U';Tt Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL TEMP POWER POLE
(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:$300
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. APN Number:35910057.00 Occupancy Type:
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 PERMIT 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, 180 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 C
with all non-point source re ulations per the Cupertino Municipal Code,Section Issued by: L-� • Date:
9.18.
Signature Date l 2'—
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 inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 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
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I 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 Additionally,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 contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or autl ized age t
Compensation laws of California. If,after making this certificate of exemption,I — ' Date: r c,//2--
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 Hork's
APPLICANT CERTIFICATION for which 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
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 accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand 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
12 -T�
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTiNO (408)777-3228 •FAX(408)777-3333• building(c�cupertino.orq MISC
[:]PLUMBING ❑MECHANICAL ELECTRICAL MUSCELLANEOUS
PROTECT ADDRESS2 }}
001 ►Z,)JRiGt,,LS A-V a e,r1�11u �A APN
OWNER NAME PHONE w p E-MAILV I
A� U 1 Y1vFf�JNrh S LCL — 1 (� C�✓��d.c�
STREET ADDRESS' S ss CI1Y, STATE,ZIP FAX Q x Ave Lo s A CA q 4024
CONTACT NAME A PHONE E-MAIL
tax �� u 6sv -4� 2 -OS$'1
STREETADDRESS CITY,STATE, ZIP FAX
153� (, 0 5SQ l �rvr: o S CA 4 o-2-`f
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT +CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGWEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME. L LICENSE NUMBER L7 / 2 LICITTSE TYPE 3 BUS.LIC# 32-1 7 3
� L�U L��nS ,(��
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, , PHONE
IS'�j Vil,�SS.ex hve STATEZIP Lc s A l-�S c.� 1q0So - �2 -0y��
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.ITC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF `ZSFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREAJA NO FLOOD ZONE NO EICHLER HOME? W NO
DESCRIPTION OF WORK
TOTAL VALUATION: RECEIVED BY: in
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.,have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building constructions I thorize representatives of Cupertino to enter the above-identi d propprty for inspection pu{poses.
Signature of Applicant/Agent: -`"t C, Date: �
fC� /-2—
SUPPLEMENTAL itFORMATION REQUIRED OFFICE USE ONLY
VER-THE-COUNTER
c
❑ EXPRESS
Y
U
T
❑ STANDARD
U
❑ LARGE
G
❑ MAJOR
MEPMscAppj011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20699 rodriguez ave. DATE: 01/10/2012 REVIEWED BY: bobs.
APN: BP#: VALUATION: $300
y PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex lex PENTAMATION 1 REAP14
USE: PERMIT TYPE:
WORK install temp power pole.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $44
TOTALS: 1 $44.00
Elec.Plan Check 0.01 hrs $0.00
Elec.Permit Fee: 1EPERMIT
Other Elec.Insp. 0.0 hrs L$44.00
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the preffindina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Lee Resohition 11-0.53 Lff ,','1.%11) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Administrative Fee: ]ADMIN $41.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRA VDOC $44.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: 1 $174.50 $0.001 TOTAL FEE: 1 $174.50
Revised: 1/01/2012
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY ## 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35910057.00
DATE ISSUED. . . . . . . : 01/10/2012
RECEIPT #. . . . . . . . . : BS000015725
REFERENCE ID # . . . : 12010078
SITE ADDRESS . . . . . : 20699 RODRIGUES AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : AC & D LIU INVESTMENTS LLC
ADDRESS . . . . . . . . . . : 1585 WESSEX AVE
CITY/STATE/ZIP . . . : LOS ALTOS, CA 94024
RECEIVED FROM . . . . : ALEXANDER LIU
CONTRACTOR . . . . . . . : ALEXANDER LIU LIC # 32973
COMPANY . . . . . . . . . . : AC LIU CONSTRUCTION, INC
ADDRESS . . . . . . . . . . : 1585 WESSEX AVE
CITY/STATE/ZIP . . . : LOS ALTOS, CA 94024
TELEPHONE . . . . . . . . : (650) 492-0857
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 300 . 00 1. 00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 300. 00 0.50 0. 00 0 .50 0. 00
1EPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00
1ERT<200 UNITS 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 AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 174 .50 MC
---------------
TOTAL RECEIPT 174 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER