12030136 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21820 MONTE C1- CONTRAC TOR: K& M PER3nT NO: 12030136
DEVELOPMENTINC
OWNER'S NAME: MONTE COURT LLC PO BOX 2535 DA I E IssaE:o:03/28/2012
OWNER'S PHONE: 4083905127 CUPERTINO, CA 95015 PROSE.NO:(408)253-9787
❑ LICENSED CONTRACTOR'S DECLARATION r r F-
Bli I1.DIN'C PE:R.\II'I'INFO: .)Lac r:f.t:cr I•Luyus
License Class Lie,4 5741&1-4 F- r r
t,/e )lec:u Resn>r:z"rh\L co)I.IeRclnt.
Contmclor 7� � ��✓r"lK7/ ' ate !t
1 herebyaffirm Ihnl l nm licensed under Ili JOB DESCRIPTION': INS'I�ALL"I FMl'POWI'.R 100 ANIP
provisions of Chapter
(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 penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to sell'-insure for Worker's
Compensation,as provided for by Section 3700 of Elie Labor Code,for the
performance of the work for which this permit is issued. Sq.FI Fluor Area: Valuation:S>o0
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,lin the performance of the work for which this
\P\Somber:32619083.00 ocrnp:mcv l'rpc:
pcnnil is issued.
APPLIC.\N"I'CER'1'IFI(:,\'PION
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 18, DA-�S FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City ofCupertino against liabilities,judgments,
costs,and expenses Which nary accrue against said City in consequence of the z.C J�p Gi
granting of this pcnnil. Additionally,the applicant understands and will comply Issued by: Dale. U
With all non-point source regulations per Elie Cupertino Municipal Code,Section
9,18.
32� !1 RF.-ROOFS:
Signator• Ua1c All roofs shall be inspected prior to any roofing material being installed. If a rooris
installed without first obtaining an inspection.I agree to remove all neW materials for
inspection.
❑ ON%'NER-L4WR DECLARATION
'.
hereby affirm that I am exempt from the Contractor's License Law for one of Signature o1'ApplicantDole.
the following two reasons: ,\1.1.ROOF CO\'E:It I,,\GS"fO ITIS CLASS":\"OR 13E:I1'F;R
I,aw
s Collier m 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)
I.as owner of the property.am exclusively contracting with licensed contractors to IIA%\RDOUS.MA'ITRIA S DISCLOSURE:
construct the project(Sec.7044,Business&Professions Code)- 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505.25533,and 25534. 1 Will
hereby affirm under penalty of perjury one of the following threemaintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Safety Code,Section 25532pp should I store or handle hazardous
I have and will maintain a Certificate ofConsenl to self-insure for Worker's material. Addilionally,should I use equipment or devices Which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code for Ilse air contaminants as defined by'the Bay Area,\ir 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 Ibr by the Ilealth&Safely Cade,,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code•for the performance of the work for which this 3 2 8
permit is issuedOwner or authorized agenC
.
I certify that in the performance or Elie work for which this permit is issued.I shall
not employ any person in any manner so as to become subject to Elie Worker's
Compensation laws of Calilm-nia. B',after making this certificate ofecemption, I CONS I"RUC"TION LENDING AGENCY
become subject to Elie Worker's Compensation provisions of the Labor Code. I must I hereby affirm Thal there is a construction lending agency Ibr the performance of
I'onhWith comply with such provisions or this permit shall be deemed revoked work's lin rshich this permit is issued(Sec 3097,Civ C.)
Lender's Same
APPLICANT CERTIFICATION Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to complywith all city and county ordinances and SWEE: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 ,Ut(:III'TF.(a"S DE:C.1.:\It:\'1'IOV
indemnity 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 illy'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 Dale,
n
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp:: Rng.: Sub: Blk: Lot :
APN . . . . . . . . : 32619083 . 00
DATE ISSUED. . . . . . . : 03/28/2012
RECEIPT # . . . . . . . . . : BS000016382
REFERENCE ID # . . . : 12030136
SITE ADDRESS . . . . . : 21820 MONTE CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER ' . . . . . . . . . . . . : MONTE COURT LLC
ADDRESS . . . . . . . . . . : 21820 MONTE CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM M KANG
CONTRACTOR . . . . . . . : MARTHA KANG LIC # 22244
COMPANY K & M DEVELOPMENT INC
ADDRESS . . . . . . . . . . : PO BOX 2535
CITY/STATE/ZIP CUPERTINO, CA 95015
TELEPHONE . . . . . . . . : (408) 253-9787
FEE ID UNIT - QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
------- --- ------------- ---------- -------- -- ---------- ---------- ---- --- - - -
-ADMIN HOURS 1 . 00 41. 00 0 . 00 41 . 00 0 . 00
1BCBSC VALUATION 500 . 00 1 . 00 0 . 00 1 . 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
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 AX
---------------
TOTAL RECEIPT 174 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----- --------------------- ------- ----- -- - -- ------
402 TEMPORARY POWER
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21820 Monte Court DATE: 03/28/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK Installation of tem ora ower 100 am
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $44
TOTALS: $44.00
d h•cb. !'/on Check Phuob. Plan Che.-e6 Elect. Plan Check 0.0 hrs $0.00
bhcit Perwir Fee: Plronh. Persil!Fcec Elect. Permit Fee: IEPERMIT
Orh,,, Mceh. lnrp. Other Phunb Insp. Other Elec.Insp. 0.0 hrs $44.00
,I/aeh. htep. Fre: Muurb. Garp. Fee- /tier./asp. Fre:
NOTE: This estimate does not includejees due to other Departments fi.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District eta). Thesefees are based an the prelimina in ormation available and are only an estimate. Contact the Dent for addn7 info.
FEE ITEMS (Fee Resnhuion 11-053 Eff 71111 U FEE QTY/FEE MISC ITEMS
Plan Chuck Fac:
Suppl. PC Feu
PME Plan Check: $0.00
Permit Fee:
Suppl. hasp l-ee
PME Unit Fee: .$44.00
PME Permit Fee: $44.00
C'onsinic•tion Tax:
Administrative Fee: 1ADMIN $41.00
Work Without Permit? O Yes (E) No $0.00
Aclt•onced Planning Fires:
Travel Documentation Fee: ITRA VDOC $44.00 A
StronMotion Fee-
L_ 1BSEISMICR $0.50 Select an Administrative Item
131de Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE $174.5
Revi ed: 1/j9&6'12
GENERAL PERMIT APPLICATION M E p
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 I
sc
CUPERTINO (408)777"3228• FAX(408)T77-3333• buildinDf°Dcuoertino.orD
PLUMBING ❑MECHANICAL ELECTRICAL IvIISCEU.ANFOUS
PROJECT ADDRESS v�>~ c AM# - 2LP LG 6�
owNERNAME H/a ��„��'' by i PH° .3SlJ S�Z 2 /9'elo�(�G''Y�Lc
STREETADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL.
STREETADDRESS CITY,STATE, ZIP FAX
OwNER ❑ Owm.BUIIDER ❑ OwNERAGENT ❑ CONraACTOR ❑CONTRACTOR AGENT ❑ ARCPoTECT ❑QGDNEER ❑ DEVELOPER ❑ TENANT
mxraA RNAME TlJZ L� i.� llCFNSE ER�/ LICENSE TYPE BUS.LICA
v
Alld STRMEEATNAY NAME E-MAIL
' 1+ -W @ Z53 q
'
D RESS
PHONE
ARCHITECTIENGINEER NAME LICENSE NUMEER BUS.LIC p
COMPANY NAME E-MAIL. FAX
STREET ADDRESS CITY.STATE,ZIP PHONE
USE OF SFO m DUPLEX ❑ MULTT-FAMILY PROJECT`N WIDLAND ❑ YES PROJECT IN [3 YES; 15THEBIOGAN ❑YES
BUDDING: ❑MmxmmAL URBREA AN INTERFACE A -111d;71 FLOOD ZONE A
NO EJCHLFRHO. E NO
DESCRIPTION OF WORK
TOTALVALUATION: � �-� RECEIVED BY:
By my signature below,I certify to each of the following. I am the property owner or anthorized agent to act on the property owns Ver's behalf. I have read this
application and the information I have provided is correctL#have read the Desorption of Work and verify it is accurate. I agree to comply with all applicable local
atdinancq and state laws relating to building RpnstoctiOn. I authorize representatives of Cupertino to cater the above-idend5ed property fm inspection purposes.
Signature ofApplicandAgcat Date:
SUPP TI REQ11>•RED OFFICE USE ONLY
y
OVER-THE-COUNTER
❑ EXPRESS
Y
V
❑ STANDARD
u
S ❑ LARGE
❑ MAJOR
AEPAdOcApp_201 Ldoc revised 06111111