12050078 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20185 SUISUN DR CONTRACTOR:YANG'S CONSTRUCTION PERh11T NO: 12050078
OWNER'S NAIVE: CHOU CHIH-TAI AND HWANG TSORNG 11831 SOUTHWOOD DR DATE ISSUED:05/072012
OWNER'S PHONE: 4083661260 SARATOGA.CA 95070 PHONE.NO:(408)374-8988
❑ LICENSED CONTRACTOR'S DECLARATION JOBDESCRIPTION: RESIDENTIALU COMMERCIAL
License Class LLiic.q TEMPORARY POWER POLE
Contractor nn [Nzy✓lin 104 Date
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.
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 whichthis permit is issued. Sq.FI Floor Area: Valuation:$500
1 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:36928013.00 Occupancy Type:
permit is issued. _
APPLICANT CERTIFICATION / - e '
I certify that I have read this application and slate that the above info ation 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 DAY M LAST CALLED INSPF,CTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, //
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: L Date: 7
with all non-point source regulations per the Cupertino Municipal Code, ection
9.18.
�7 Rt:ROOFS:
Signature -Date— -- 1/ 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-BUILD: F,CLARATION
I hereby affirm that I em exempt train the Contractor's License Lew for one of Signature of Applicant: Date:
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(Sce.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penally 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 1 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 whichthis 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 25505,25533.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.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONS IRI ICI'ION 1. . ,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 stale 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
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
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
f
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36928013 . 00
DATE ISSUED. . . . . . . : 05/07/2012
! RECEIPT #. . . . . . . . . : BS000016739
REFERENCE ID # . . . : 12050078
SITE ADDRESS . . . . . : 20185 SUISUN. DR
SUBDIVISION : . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER CHOU CHIH-TAI AND HWANG TSORNG
ADDRESS 20185 SUISUN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : LIAN YANG
CONTRACTOR LIAN YANG LIC # 27918
COMPANY YANG'S CONSTRUCTION
ADDRESS 11831 SOUTHWOOD DR
CITY/STATE/ZIP . . . : SARATOGA, CA 95070
TELEPHONE . . . . . . . . : (408) 374-8988
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- --------- ---------- ---------- ----------
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 133 .50 0. 00 133 . 50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 133 .50 VISA
---------------
TOTAL RECEIPT 133 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION:
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Temporary Power
SFD or Duplex PENTAMATION 1REAP14
i.S/:: PERMIT TYPE:
WORK TEMP POWER POLE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID AMPS VOLTS BP FEES
Service (incl. Temp. Power) 1ERT<200 200 <=600 $44
I 0o, Plumb 1'lon(fit(K
Elec. Permit Fee: IF.PERMIT
r' ';'::. $44.00
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelindna in ormation available and are only an estimate Contact the Det or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS
PAIL (:h"J, Fee:
Sv.,pl>/. )'(- !".
Phim").:alcch.!7 /dc
PME Unit Fee: $44.00
PME Permit Fee: $44.00
(n,t,trruaimr 7b,r:
wc
Work Without Permit? 0 Yes Q No $0.00
.1thv:,;rr,:Ph-lj iiq;
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255
CUPERTINO (408).m-3228•FAX(408)777-3333• buildina(o7cuoertino.ora " SC
20560
PLUNMING ❑MECHAMCAL ELECTRICAL ❑MISESTrANFDUS
PROJECT ADDRESS O AFN a W/n oi 9_`i/
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OWNER NAME / / PHONE EMAIL
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CONTACT NAME J
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CONTRACTOR: LICENSENUMB �_'2Drl TYPE BUS.LICA
COMPANY FAX
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ARCHTTECUFNGINEZR NAME LICENSE NUMBER BUS.DC A
CONMANY NAME' E-MAIL FAX
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USE OF ❑SFDWDUPIEt ❑ MUI.TLFAAGLY iPRmFCTBJWILDIAND ❑ YES PROIECTIN ❑YES 7S THE BLDG AN ❑YES
BUILDING: ❑cow, aAL URBAN RO'DIFACE AREA C3 NO FLOOD ZONE [3 No MCHIFR HOME? [3 NO
DFSCAIPRON OF WO
TOTAL VALUATION: ,SUV RECEIVED BY: vl L
By my signaoae below,I certify to each of the follawiog. I am the property owner cranthorlzed agent to act on the property owed s behalf I have rmd this
application and the information I have provided is ranch j have read the Description of Work and verify it is arum. I agree to comply with all applicable local
ordinances and state laws relatig to bmldm = I authorize repre5eataWm of Copertioo to enter the above-identifi err/for iaspecdon putposm.
Sigaaaae of AppSrmr/Agmt: Date: l�
SUPPLENU24T 'INF TION 1.2EQUMM ONLY
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MEPMuc4pp_20ll.doc revised 06121/11