12040104 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20550 BLOSSOM,LN CON'IRACI'OR:RYAN IIU PF.RNIH NO: 12040104
OWNER'S NAME: PO-YANG TIEN 401 S NORFOLK ST DATE ISSUED:04/182012
OWNER'S PHONE: 4082192390 SAN MATEO,CA 94401 PRONE NO:16501759-6325
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.p M—
MECH r RESIDENTIAL r COMMERCIAL r
Contractor &W Dale - C3 fJ
1 hereby affirm that I am licensed under the provision of Ch ter 9 JOB DESCRIPTION:TEMPORARY POWER POLL
(commencing with Section 7000)of Division 3 of the Business&Professions
Cade 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 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:$500
Section 3700 critic Labor Code,for the performance of the work for which this
permit is issued- APN Number:35918026.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
cored. I agree to comply with all city and county ordinances and stale 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 may/� / �/ p
with all non-points a regulations cr the Cupertino Municipal Code,Section Issued by: / /V /4r,:w Date:
9.18.
SignDate
ell RF.-ROOFS:
❑ OWNER-BUILDER DECLARATION All roots shall be inspected prior to any roofing material being installed. Fa roof is
installed without first obtaining an inspection.1 agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one or inspection.
the following two reasons:
I,as owner of the property,or my employees with wages a5 their sole compensation, Signature of Applicant: Date:
will du 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 BE ITER
construct the project(Scc.7044,Business&Professions Code),
1 hereby affirm under penalty of perjury one of the following three IIAZARDOUS NIATERIAI.S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Conscnl to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 I Iealth&
performance ollhe work for which this permit is issued. Safety Code,Section 25532(:)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 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 Nlunicipal Code,Chapter 9.12 and the
,
I certify that in the perfomsmsc al'the work for which This permit is issued,I shall Ilealth&Safety ' de,Sections 25505,25533.and 255
not employ any person in any manner so as to become subject to the Worker's Owner or a t rzed agent: /
Compensation Imes ol'Calilbmia. 11',alter making this certificate of exemption,I - Date:
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 work's
APPLICANTCERTIFICATION 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 ARCIIITECT'S DF.CLARA I-ION
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
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20550 Blossom Lane DATE: 04/18/2012 REVIEWED BY: Sean
APN: ��oa BPIF: U Q VALUATION: $500
"PERMIT TYPE: Electrical Permit PLAN C ECK TVP : Alteration /Addition / Repair
PRIMARY SFD Or Duplex PENTAMATION 1REAP14
USE: p PERMIT TYPE:.
—71
WORK Installation of temporary ower pole.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power CERT<200 100 Amps $44
TOTALS: $44.00
11"ch. Ilan!'hrrA Phand. Alco ChceA Elec. Plan Cheek 0.0 hrs $0.00
1/,.,./,, /•,.,,,,p F,•,.• Mwnh. Po mit Fre: Elec. Permit Fee: IEPERMIT
i
rhh,, Ah,,h. Imp Olhe, Plnmh/m./,_ Other Elec. Insp. L2_0j
hrs $44.00
lilca
;bhrh. Imp. I•bt" /'/omit, In,/). Fr.•: !hop Pcm.
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,ere. . These fees are based on the prelindina information available and are only an estimate Contact lite Dept for arida?info,
FEE ITEMS (Fee Resohdion 11-053 Efl. ZW/ l/ FEE QTY/FEE MISC ITEMS
Plan Chunk Pre:
Stipp/. PC Fev
PME Plan Check: $0.00
Prl'rnil Fee:
Supp/. lltsp l to
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Cun.snvlrvion Tax:
Administrative Fee: IADMIN $41.00
Work Without Permit? Yes Q No $0.00
.-0drrnrrrrl Plnnr+inp Pers:
Travel Documentation Fee: IT"VDOC $44.00
Suone Motion Pee: IBSEISMICR $0.50 Select an Administrative Item
131de Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE:, $174.50
Revised: 04/01/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 M I /� A
CUPERTINO (408)777-3229• FAX(408)777-3333•buildinaC�cu°e tinO.o G / •0 0 ///l/D� S(v'
PL/UmoiNNG ' b1ECHAMCAL LYRICAL []MISCELLANEOUS
PROIECTADDRESS D✓�l'V H/✓/0 '7-�1n "FNM (3S
OWNFANAME / 6,717e �t7 n ° Z/ 13 O E. �
STREET ADDRESS '7a L )/'I�So " G. ./% FAX / I
CONTACT NAME ,( � /�/� /1 1 E MAm fib P J 1V V Q 1 J
Sl-REEF AD°RES /j„c CitY,S7A 7�P L��[ G'' FAX 11 '
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CDMRACTOR ❑CONTRACTOR AGENT ❑ AROur= 0e4GINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME LICENSE NUMBER7J� LICENSE TYPE II BURDCM�
cGhmANYNAME �•.. MAD. r, /Q 1hw�/e IBJ,Pw PAAxxN�.
SS1tELTT A0DRE54/�`in�Il �/(�vwIc.L'S�• �lQl�� " S/7
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.DC p
COMPANY NAME' - E-MAIL FAX
- SrREEPAODRESS =.STATE,IIP FBONE
USE OFar0UP1EC 11MULTFFAKILY FROmrr IN WIDLAND ❑ YES PRUIECTIN ❑YFS IS THE BLDG AN ❑YES
BUDDING: ❑cOMMEROAI. UREANDITEBFACEARFA ❑ NO FLOOD EDNF ❑NO eOIIFRHOME7 ❑NO
DFSCRD'TION OF WORK
q,�^
TOTAL VALUATION: RECEIVED BY:
By my sigoenne below,I certify to each of the fDllowmg. Ithe property awncr err antharizcd agent m act an the property owner's behalf I have read this
application and the int'Dtmation 1 hav 'ded is t. read the Description of Work®d verify it ercotata m, ttgtly with all applicable local
tuxliz3m s and at laws relatmg tuns aria representatives of Cupertino m ester me ab -i e[ty for inspection pu4poses.
Signature ofApptitanNAgeoe Dare: L
LEMENfAL INFORMATION REQUIRED OFFICE USE ONLY
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MPPMITcApp 20II.doc revised 06121/11