12050214 CITY OF CUPERTINO BUILDING PERMIT
ROILDING ADDRESS: 1012 NOVEMBER DR CONTRACTOR:SANDIUM PERMIT NO: 12050214
OWNER'S NAME: DOCKINS KAREN A ET AL 4223 VERDIGRIS CIR DATE ISSUED:05/30/2012
OWNER'S PHONE: 4084833715 SAN JOSE,CA 95134 PIIONE NO:(408)8949072
❑ LICENSED CONTRACTOR'S
DECLARATION BUILDING PERMIT INFO: BLDC r ELECT r PLUMB r
License Class (.�L_V Lic.H ra oO `0 I r r r
�1 MECH RESIDENTIAL COMMERCIAL
Contractor YA.tn.r�lSu„ Date.. 30 Iv
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE FURNACE AND ADD A/C
(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 or 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. Sq.Ft Floor Area: Valuation:56583
I 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
pcmtit is issued APN Number:36215011.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned properly 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 orthe
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: ��11_v /%U/-p Date:
9.18. f
Signatur�Lt.�- � 5
Date '?-9/2,
RF.-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any rooting material being installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owncr of the property,or my employees with wages as 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 BETTER
construct the project(Sec.7044.Business&Professions Code).
1 hereby affirm under penally of perjury one or the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent 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 Ilealth&
performance of the work for which this permit is issued. Safety Code,Section 25'32(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I 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 Municipal Cbde,Chapter 9.12 and the
P Health&Safety Code.Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Worker's Or a Ihorized agtn
Compensation laws of Calitirmia. If,after making this certificate of exemption,I wne Dale:
become subject to the Worker's Compensation provisions of the Labor Code,I muss
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
APPLICANT CERTIFICATION 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 stale laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned properly 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 ARCHITECT'S DECLARATION
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
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36215011. 00
DATE ISSUED. . . . . . . : 05/30/2012
RECEIPT #. . . . . . . . . : BS000016943
REFERENCE ID # . . . : 12050214
SITE ADDRESS . . . . . : 1012 NOVEMBER DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DOCKINS KAREN A ET AL
ADDRESS . . . . . . . . . . : 1012 NOVEMBER DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95.014
RECEIVED FROM . . . . : YIU-HANG LEE
CONTRACTOR . . . . . . . : MICHAEL LEE LIC # 28867
COMPANY SANDIUM
ADDRESS . . . . . . . . . . : 4223 VERDIGRIS CIR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95134
TELEPHONE . . . . . . . . : (408) 894-9072
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 6, 583 .00 1 . 00 0 . 00 1 . 00 0. 00
1BREMAIRHA NO.UNITS 1 .00 65 . 00 0 . 00 65 . 00 0. 00
1BSEISMICR VALUATION 6, 583 . 00 0 .66 0 . 00 0 .66 0. 00
1MFR=<100 UNITS 1 . 00 130 . 00 0 . 00 130 .00 0. 00
1MPERMITFE FLAT RATE 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 325 .66 0 . 00 325. 66 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 325. 66 VISA
---------------
TOTAL RECEIPT 325. 66
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
12 �`� EP
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 I
GUPERTINO (408)777-3228•FAX(408)T77-3333• building(EDcuoerino-oro
IC
❑PLUMBINGMECKAMCAL ELECTRICAL MISCELLANEOUS
PROTECT ADDRESS �o\? � e _ APN"
OWNERNAME , /�I Lv 'I -_ 't> 1�j`. I PHONE 4c;2
49z 37�S EMAIL
STREET ADDRESS a5 w CITY, STATE,ZIP TTOOJ �( TAX
CONTACT NAME J PHONE E-MAIL
TIME r/Li✓j',r�f/G O
STREET ADDRESS CITY,STATE. ZIP FAX
❑OWNER ❑ OWNETt-BUILDER.
\ ❑ rOWNER AGENT CONTRACTOR ❑CONTRACTORAGENT ❑ ARCI CT ❑ENGINEER ❑ DEVELOPER ❑ TENMT
CONTRACTOR NAME p�`�1/ - I LICENSE NUMBt�F8u Q� LICEN;;E rb BUS.LICd
CDMPANY NAME /7 EMAIL �f Sa( L _-1 n n /l-'/ Ct(- L' IV�,- FAX
STREET ADDRESS 42:2,3 .0 w CT'.STATE.ZR' Q/�( PHONE I, C1 fly`'_ 9072
ARCHITECTIEdGINEFR NAME ^, /1 J LICENSE NUMBER BUS.UCL1\"v"f'X' o T l t
COMPANY NAME /" /7 E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 2fmDU LEtc ❑ MI/LTI.FAMD.Y PRomcTINw LVJD ❑ YES PRO=IN ❑ YES ISTIM BLDG AN ❑ YES
BUIDNG: []COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLFA HOME? O
DESCRBMON OF WORK
It,G, e Aid
TOTAL VALUATION: � 5 / RECEIVED BY:
By my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf I have read this
application and the information I have p ed is eottect. I have read the Description of Work and verify it is accutate. 1 agree to comply with all applicable local
ordinances and stem laws relating m t d' g wnslrucdon.- au 'ze representatives of Cupertino tD enter the above-id tified p perty for inspection puiposes.
Signature ofApplicanUAeebc `{/� Date: �/ 3D�Z
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
uQ
y OVER-THE-COUNTER
❑ EXPRESS
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m ❑ STANDARD
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❑ LARGE
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❑ MAJOR
EPMiscApp_ 011.doc revised 06/1l/11 -