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12020035 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20299 NORTHWEST SQ CONTRACTOR:C AND D FREITAS PERMIT NO: 12020035 CONSTRUCTION OWNER'S NAME: TSUI LYNN L 23610 MORREL CUT-OFF RD DATE ISSUED:0.71/08/2012 OWNER'S PHONE: 4088353980 LOS GATOS,CA 95033 --JPHONE NO:(408)353-1900 0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License class L3 Lic.# /q 13 10 5%/2 Contractor (f YD Fete LL~�r��Le9 Date MECH ' RESIDENTIAL COMMERCIAL I hereby affirm that.I am licensed tinder the provisions of Chapter 9 JOB DESCRIPTION: INSTALL TEMP ELECTRIC 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 tinder 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$87 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31639061.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save Indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: ate: Signature 0 Xez.,� Date 2v 9--/x— rl ONNINER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: 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 tinder penalty of perjury one of the following three HAZARDOUS MATERIALS DtSCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25545,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of(lie Labor Code,for(lie perfortnance of the work for which this Additionally,should I use equipment or devices which emit hazardous air 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 25545,25533,and 25534. not employ any person in any mariner so as to becorne subject to the Worker's Corti pen sation laws of California. If,after making this certificate of exemption,I Owner =1Vt•-17 --3-Aw become subject to the Worker's Compensation provisions of the Labor Code,I must L forthwith cornply with Such provisions or this pen-nit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of wrk's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city aril county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address 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 with all non-point source regulations per the Cupertino N(lunicipal Code,Section I understand rity plans shall be used as public records. 9.18. Licensed Professional Signature Date I 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: A .� 9 ,�;,f w� SQ PERMIT# /�it�� IS' OWNER'S NAME: C lir,+C4'-t 1Z.) r Gr PHONE# GENERAL CONTRACTOR: O Fart ; G . BUSINESS LICENSE# ADDRESS: X X416 t/vrn"l c,, -i f A CITY/ZIPCODE: ,6s 6do-� X13 *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 AIA Electrical IJA Lla Cc, Excavation A[A Fencing Flooring/Carpeting Linoleum/Wood Glass/ Glazing Heating ZIFS44 Insulation r6�J) / 13 d llf-o Ouc. rLandscaping Niq Lathing Masonry , Painting/Wallpaper Paving AIW Plastering A Ar Plumbing /Oh b iom o Roofing Septic Tank Sheet Metal AN Sheet Rock C j'LDh-r klL Tile Owner/Contractor Signature Date CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31639061.00 DATE ISSUED. . . . . . . : 02/08/2012 RECEIPT #. . . . . . . . . : BS000015961 REFERENCE ID # . . . : 12020035 SITE ADDRESS . . . . . : 20299 NORTHWEST SQ SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : TSUI LYNN L ADDRESS . . . . . . . . . . : 20299 NORTHWEST SQ CITY/STATE/ZIP . . . : CUPERTINO, CA 95124 RECEIVED FROM . . . . : C AND D FREITAS CON CONTRACTOR . . . . . . . : CLARENCE W FREITAS LIC # 21616 COMPANY . . . . . . . . . . : C AND D FREITAS CONSTRUCTION ADDRESS . . . . . . . . . . : 23610 MORREL CUT-OFF RD CITY/STATE/ZIP . . . : LOS GATOS, CA 95033 TELEPHONE . . . . . . . . : (.408) 353-1900 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41.00 0 .00 41 .00 0.00 1BCBSC VALUATION 87 .00 1. 00 0 . 00 1 .00 0.00 1BSEISMICR VALUATION 87 .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 ----------------- --------------- -------------------- CASH 293 .50 --------------- TOTAL RECEIPT 293 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER � 7 co ..................................... CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ` ADDRESS: 20299 Northwest Square DATE: 02/08/2012 REVIEWED BY: larry s s APN: BP#: VALUATION: $87 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY PENTAMATION USE: PERMIT or Duplex PERMIT TYPE: 1 REAP14 WORK electrical 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: IEPERMIT Other Elec.Insp. 0.0 hrs $44.00 A10TE: This 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 therelin ina information available and are o!lE an estimate. Contact the De t or addn 7 in o. FEE ITEMS '':;� ''vf:3 =�rfi '_' 'k 3 F.' ' is FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 ILI Administrative Fee: ]ADMIN $41.00 Work Without Pen-nit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 ta_ < t: 1--1. IBSELSAKU $0.50 Select an Administrative Item $1.00 SUBTOTALS: $174.50 $0.00 TOTAL FEE: E $174.50 Revised: 1/19/2012 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(abcupertino.org MISC []PLUMBING ❑MECHANICAL .ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 2,0 2 /1 J� UG r e APN# OWNER NAME LUhk\ I U I PHONE !��" �!'�/O� E-MAIL ! u n✓1 tS 0 1 10 4t 4/t Do `CU STREET ADDRESS ✓ CITY, STATE,ZIP FAX n � h !,mss 6a CONTACT NAME PHONE " '1 G� c) E-MAIL c C- o ( 0!�0 0 EET2-3 C 0►Y� STRADDRESS 2-3 L 7I C r� �� CITY,STATE, ZIP t s FAX 3 S ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT NTRACCOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ElDEVELOPER 11 TENANT CONTRACT�Z �w L[L�I`tve f�rti 6� LICENSE NUMBER n �&Sl? LICENSE TYPE 8 BUS.LIC# z-r'c�--r-�'e�'raT-L�'Ys rv'J `� / / COMPANYNA]�/-�r[) �ht1�fi5 LGr�) CU. E-MAIL /�/� �G� GhvG eC.L;N FAX STREET ADDRESS PHONE JLoI LJ /1[sv`N ! Liles�D 10. CITY,STAY �G 6 5 L_�i t 1 S6J 3 dd •3 /�o6 ARCHITECT/ENGINEER NAME LICENSE NUMBER-� Bi�.IC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ,❑YES� BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA G"I ro FLOOD ZONE NO EICHLER HOME? DESCRIPTION OF WORK 115 W e. /3 LAO A e L1 L w l7 e I C ��w S�/tlli / H (�✓! VrcOi �r r►s /"au�tU !C►^h2.i l TOTAL VALUATION: 0 RECEIVED ECEED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property er'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 td buildipg construrffoptI authorize representatives of Cupertino to enter the above-identified property for inspection poses. Signature ofApplicant/Age- - Date: - ' SUPPLE NTAL IN�ORMA OTI N REQUIRED Q OFFICE USE ONLY ❑ OVER-THE-COUNTER a ❑ EXPRESS U W ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMisc,4pp_2011.doc revised 06/21111