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12010085
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21835 LOMITA AVE CONTRACTOR:ELITE HOME PERMIT NO: 12010085 DEVELOPMENT OWNER'S NAME: JERRY LILT 2787 MOORPARK AVE DATE ISSUED:01/11/2012 OWNER'S PHONE: 6503845128 SAN JOSE,CA 95128 PHONE NO:(408)848-8370 ix LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG� ELECT� PLUMB� License Class Lic.# -1 2 S� y r , �. MECH RESIDENTIAL COMMERCIAL Contractor k /©VV-L Date 11 Y 4 2 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD SECOND ELECTRIC METER FOR 2ND UNIT (commencing with Section 7000)of Division 3 of(lie Business&Professions Code and that ray license is in full force and effect. I hereby aftirin under penalty of perjury one of the following two declarations: €have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided tier by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$200 1 have and will maintain p'orker's Compensation Insurance,as provided for by Section 3 700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35716063.00 Occupancy Type: APPLICANT CERTIFICATION I certify that l 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 indertmify 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 with all non-point source regulatians per the Cupertino Municipal Cade,SectionIssued bye Date 9.18. q Signature Date ( a 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 front the Contractor's License Law for one of inspection. the following hyo reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and(lie 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 €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 3M0 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 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 whichthis permit is issued,I shall not employ any person in any manner so as to became subject to the Worker's Owner or authorized agent: II Compensation law's of California. If,after making this certificate of exemption,I Date: 1 f 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 wark's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 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 liannless 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 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35716063 . 00 DATE ISSUED. . . . . . . : 01/11/2012 RECEIPT #. . . . . . . . . : BS000015737 REFERENCE ID # . . . : 12010085 SITE ADDRESS . . . . . : 21835 LOMITA AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . . JERRY LIU ADDRESS . . . . . . . . . . : 21835 LOMITA AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DUC C NGUYEN CONTRACTOR . . . . . . . : DUC C NGUYEN LIC # 31914 COMPANY . . . . . . . . . . : ELITE HOME DEVELOPMENT ADDRESS . . . . . . . . . . : 2787 MOORPARK AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95128 TELEPHONE . . . . . . . . : (408) 848-8370 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 200 .00 1. 00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 200 .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 1TR.AVDOC 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 VISA --------------- TOTAL RECEIPT : 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISIC (408)777-3228• FAX(408)777-3333- building(cr-cupertin ..or4 CUPERTINO PLUMBING ❑MECHANICAL /ELECTRICAL ❑MISCELLANEOUS ou 3PROJECT ADDRESS � .('� � I n�I tA APN# ,_3 _ !�, j5 I .('-�J PHONE /( MAIL OWNER NAME J P/Y Y, V�L�, ��-!1 �` �: CITY, STATE,ZIP FAX STREET ADDRESS PHONE �(/ p 3,S Y4 E-MAIL CONTACT NAME Lo C c,,S N G l��/.P/"1 Q 0 Q J FAX STREET ADDRESS A v CITY,STATE, ZIP S . ^ C, �J L �f [3ARCHITECT ❑ENGWEER ❑ DEVELOPER ❑TENANT ❑OWNER ❑ OWNER-BUIIDER ❑ OWNER.AGENT X CONTRACTOR ❑CONTRACTOR AGENT LICENSE NUMBER ^ I LICENSE TYPE � BUS.LIC# CONTRACTOR NAME E-MAIL ( �C G�( a� V t/CC() bo'Co FAX COMPANY NAME ((�� lam• J - � �:� J PRONE STREET ADDRESS 0 L� CITY,STATE,ZIP 0 0 BUS.LIC# LICENSE NUMBER ARCHITECTtENGINEFR NAME FAX E-MAIL COMPANY NAME' PHONE CITY,STATE,ZIP STREET ADDRESS y� PROJECT IN ES IS THE BLDG AN ❑YES USE OF ❑SFD or DUPLEX ❑ MUI T1-FAMIl Y PROJECT IN WILDL.AND ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO ❑CONUaRCIAL URBAN INTERFACE AREA ❑ BUILDING. /,, DESCRIPTION OF WORK OV l�/I GI e /� �� f t O� T Pig f/oc� -2 /g3 d5ck C, RECEIVED BY: C1 S t TOTAL VALUATION: r'` o ) 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 ply with have rel cable local application and the information I have prided is correct. I have onstruct . I agree to ionW authorize�representati es of Cupertino to entere Description of Work and tthe above-identified is property forinspecti n pulposes. ordinances and state laws relating g Date:_ Signature of Applicant/Agent: OFFICE USE ONLY SUPPLEMENTAL INF TION REQUIlZED m VER-THE-COUNTER ❑ EXPRESS Y U ❑ STANDARD T V ❑ LARGE ❑ MAJOR MHPMIscApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION & "",am Q. AA ADDRESS: 21835 lomita ave. TDATE: 01/11/2012 REVIEWED BY: bobs.. lam j APN: BP#: VALUATION: $200 PERMIT TYPE: Electrical Permit I PLAN CHECK TYPE: Alteration /Addition / Repair PRIN[AIiY SED or Duplex PENTAMATION 1 REAP2 CT p PERMIT TYPE: WORK add second elect. meter for 2nd unit. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 100 Amps $44 TOTALS: $44.00 --T T- Elec.Plan Check 0.0 Frs $0.00 Etec.Permit Fee: 1EPERMIT L1L Other Elec.Insp. 0.0 hrs $44.04 jVOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These,Les are based on the prelintina information available and are only an estimate. Contact the De t or addn 7 in o. FEE ITEMS FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Administrative Fee: 1 ADMIN $41.00 Work Without Permit? 0 Yes (Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 rvlotio,- Fee:: IBSEISMICR $0.50 Select an Administrative Item - SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50 Revised: 1/01/2012