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12020032 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20655 SCOFIELD DR CONTRACTOR:JEREMY MAO INC PERMIT NO: 12020032 OWNER'S NAME: STANLEY&RITA LEE 19935 SEAGULL WAY DATE ISSUED:02/08/2012 OWNER'S PHONE: 4087258891 SARATOGA, CA 95070 PHONE NO:(408)449-9942 ❑ LICENSED CONTRACTOR'S DECLARATION Fu BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# 3-1 ,2e5�t�2, MECH RESIDENTIAL COMMERCIAL Contractor __rf:9A440 , Date JOB DESCRIPTION: TEMP POWER POLE 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:$400 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:35909010.00 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 INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued by� Date: 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. RE-ROOFS: Signature Date ?�1 2-- 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. ❑ 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) 1,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. 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 I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25.505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent, Date: permit is issued. I certify that in the performance of the work for which this permit is issued,I shallr� 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I 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 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: 20655 scofield ave. DATE: 02/08/2012 REVIEWED BY: bobs. APN: BP#: VALUATION: $400 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY PENTAMATION 1 REAP14 USE: PERMIT or Duplex PERMIT TYPE: WORK install temp power pole. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $44 TOTALS: $44.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: I EPERMIT Other Elec.Insp. 0.0 hrs $44.00 NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public II'orks,Fire,Sanitary Sewer District,School District,etc:.). TheseLees are based on the relinina in orntrttion available and are onl an estimate. Contact the De. t or addn'1 in o. FEE ITEMS 3 s�>¢ I 1-.0J; � 1'3'�' 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 Pen-nit:' 0 Yes Q No $0.00 Travel Documentation Fee: ITRA JIDOC $44.00 )L: o Fee. IPSEISAKC-R $0.50 Select an Administrative Item ssion ee� IBCaSC $1.00 SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50 Revised: 1/19/2012 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35909010 . 00 DATE ISSUED. . . . . . . : 02/08/2012 RECEIPT # . . . . . . . . . : BS000015955 REFERENCE ID # . . . : 12020032 SITE ADDRESS . . . . . : 20655 SCOFIELD DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : STANLEY & RITA LEE ADDRESS . . . . . . . . . . : 20655 SCOFIELD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JEREMY MAO CONTRACTOR . . . . . . . : JEREMY MAO LIC # 26422 COMPANY . . . . . . . . . . : JEREMY MAO INC ADDRESS . . . . . . . . . . : 19935 SEAGULL WAY CITY/STATE/ZIP . . . : SARATOGA, CA 95070 TELEPHONE . . . . . . . . : (408) 449-9942 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 400 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 400 . 00 0 . 50 0 . 00 0 . 50 0 . 00 lEPERMITFE 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 visa --------------- TOTAL RECEIPT 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- --------------- 402 TEMPORARY POWER Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: O "�� PERMIT# Z2 �� -7 OWNER'S NAME: ��' �' PHONE# r� y GENERAL CONTRACTOR: ^ //tlC-. BUSINESS LICENSE# Z- ADDRESS: CITY/ZIPCODE: 4:2 pt *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 and complete 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 Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333- building(D_cupertino.org CUPERT{NO IMISC 2 c� o� !' ❑PLUMBING ❑MEGHA)`IICAL ❑ELECTRICAL ❑MIS U� PROJECT ADDRESS e�� . A # OWNER NAME ONE 446 E-MAIL STREET ADDRESS 2S• *,e_t fiXP;J4 Pr- CITY, STATE,ZIP Q/=�r� FAX CONTACT NAME ' .' J v PHONE � E-MAIL t STREET ADDRESS ��r � CITY,STATE, ZIP � 0 r yJ FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME S� LICENSE NUMBER 1 LICENSE TYPE6 BUS.LIC# 2�12f COMPANY NAME �ekr11AW INC E-MAIL FAX _17 STREET ADDRESS pff z� G�� 4Y CITY,STATE,ZIP PHONE �� ARCHITECTIENGINEER NAMELICENSE NUMBER BUS.LIC# AZA. COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK D�R OtvsPir pole- TOTAL VALUATION: RECEIVED BY: t 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.,j 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 construction"I authorize representatives of Cupertino to enter the above-identified property for inspection poses. Signature of Applicant/Agcnt: Date: Z z 7-0 ?� SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-C LINTER a ❑ EXPRESS U w ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMzscApp_2011.doc revised 06/21/11