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12040127 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1035 PENNINGTON LN CONTRACTOR ) PERMIT NO: 12040127 14 OWNER'S NAME: CHANG JUNG-HUI AND TSAI CHING-FEN LLJ DATE ISSUED:0424/2012 LW OWNER'S PHONE: 4088216025 � PHONE NO: z-hs LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class e Lic.fl e&4P�_1 r r r MECH RESIDENTIAL COMMERCIAL Contractor %ZI!Z-1 Date k��-�-�lZ 1 hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APPLICANT CERTIFICATIONAPN Number:36204028.00 Occupancy Type: 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 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 nacre against said City permit. rs consequence of the 180 DAYS FROM �T CAS LED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section rL 9.18. Issued by: ' Date: Signature ,`ofi_i Date �t_ 7 ❑ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material beug installed-If a roof is hereby affirm that l 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. I,as owner of the property,or my employees with wages as their sole compensation. ,J will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: y6&,-e/ Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1 hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's 1 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 25505,25533,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(x)should 1 store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air permit is issued. 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 1 certify that in the performance of the work for which this permit is issued.I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any personin any manner so as to become subject to the Worker's Compensation laws of Califomia. If,after making this certificate ofexemplion,1 Owner or authorized agent: become subject to the Worker's Compensation provisions of the Labor Code,1 must Dale: forthwith comply with such provisions or this permit shall be deemed revoked, CONSTRUCTION LENDING.AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the perfommnce of work's I certify that I have read this application and stale that the above information is for which this permit is issued(Sec.3097,Civ C.) correct. I agree to comply with all city and 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 l iabiIities,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 Municipal Code,Section I understand my plans shall be used as public records. 9.18. r � yLicensed Professional Signature Z CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36204028 .00 DATE ISSUED. . . . . . . : 04/24/2012 RECEIPT #. . . . . . . . . : BS000016608 REFERENCE ID # . . . : 12040127 SITE ADDRESS . . . . . : 1035 PENNINGTON LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : CHANG JUNG-HUI AND TSAI CHING- ADDRESS . . . . . . . . . . : 1035 PENNINGTON LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHUNG Y WONG CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY :. . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . , TELEPHONE . . . . . . . . : 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 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 VISA --------------- TOTAL RECEIPT 174 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ---------------------------- -------- -------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION tADD.RESS: 1035 PENNINGTON LN DATE: 04/24/2012 REVIEWED BY: LARRY S BP#: 'VALUATION: $500 ^PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $44 TOTALS: ,, $44.00 c He,h. Phm C'hec'k Numb.P/au(:h:rk Elec. Plan Check 0.0 hrs $0.00 hI cjj.I',•rn+it Fire: F,11 P .rmir Fre: Elec. Pemtit Fee: IEPER,bI/T 0113;:r.11"A hrpp. Oihtr Phimh lnsp. Other Elec.Insp. 0.0 hrs 1 $44.00 al uL.hu/;.F2,•: Plumb. /rap. Elm. hr>P. NOTE: This estimate does not includejees due to other Departments(i.e Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on the Prefindna information available and are only an estimate Contact the De t or addn'l info, FEE ITEMS (Fce Rccolmion 11-053 Eff 711111) FEE QTY/FEE MISC ITEMS I'hrn Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Pel mit l cu: Supp! Insp Fee PME Unit Fee: $44.00 PME Permit Fee: $44.00 Cons/ruction Tm. Administrative Fee: IAD,NIN $41.00 Work Without Permit? Yes (F) No $0.00 Advanced Plannin;; Fres: Travel Documentation Fee: ITRA VDOC $44.00 Strong,Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item Bid', Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50 Revised: 04/01/2012 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 950143255 M ' w CUPERTINO (408)777-3228•FAX(408)777-3333•buildingCEDcuoertino.orD (v' ❑PLUMBING Z'� ❑AFCHANIC�AL ELECTRICAL ❑MISCIMLAIMOUS PRODiCI'ADDRESS /O AMP OWNER NAME •'� - PH ` ]` _�/\ .MAlar �Nr --VV lJ J STREETADDRESS CITY.STATE,ZIP FAX CONTACT NAME Ajfjtsy L✓O�Vc�/ PEONE¢6e_J?00�i ye EMAD. STREETADDRESS /' CITY.STATE, IIP FAX �d �hlRb USS � as t' Xfo�o 13 OWNER ❑ OWNER-BUIDME ❑ OWNNIAGNNT �rmmmACrOR ❑CONTRACTOR AGENT ❑ AR== 11 ENGINEER ❑ DEVELOPFA 11 TENANT CONTRACTOR NAME ASD LICENSE v L[CENSE�IPE EVS.LICA COMPANY NAME /7 E-MAR. J' FAX 7 - MEET ADDRESS CITY.STATS,z.� PfIONB s .+fA�CoAZJ GGY � ,} C%¢" O�Q ARCHMEC IENGINIER NAME LICENSE NUNWER BUS.LIC B COMEANYNAME E-MAIL FAX STREET ADDRESS CITY,STATE ZIP PRONE USE OF ❑SFOmIUPTFX 11 MULTI-FAXILY PRo=IN WTDTAND ❑ YES PROTECT IN ❑YES tSTHEBiDGAN ❑YES BINDING: ❑COTM¢IICIN- URBANQARAFACEARPA 13NO FLOOD ZONE 11 NO ETOIPRHOMIO E3 NO DESCRIPTION OF WORK E Y O.tAir !e$r( MTAL VALUATION: - RECEIVED BY: By my signaft below,I certify to each If the following: I am the property oWocr or authorized agent to act w the prop owuels behalf I have read this application and the information I have provided is correct have read the Desorption 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 M enter the above-identified property for inspection pu@oses. Signature:of AppticaudAgene Daze: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY y ❑ ovm-nm-COUNTER ❑ EXPRm Y U ❑ STANDARD U 3 ❑ LARGE r_ ❑ MAJOR MEPA&c.Ipp_2011.doc revised 06121111