12050179CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18760TUGGLE AVE
OWNER'SNAME: LAHAVRONEN
OWNER'S PHONE: 4084274546
❑ LICENSED CONTRACTOR'S DECLARATION
License Class/,._ Lic.O� ,� D 6 L4
Contractor Date- (7 5 / ! S / 1 Z
1 hereby affirm That I em Imensed under the provisionsof 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 which this permit is issued.
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
pcmnn is issued.
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
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this pemnit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature /2 / Date 0 L? �2
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044. Business & Professions Code).
CONTRACTOR: BAY AREA CUSTOM PERMIT NO: 12050179
BUILDERS INC
1002 S DE AN7-A BLVD SFE AI DATE ISSUED: 05232012
SAN JOSE, CA 95129 PHONE. NO: (408).4 6-1200
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: INSTALLATION OF TEMPORARY POWER POLE( 00AMP)
Sq. Ft Floor Area: I Valuation: $300
APN Number: 37527022.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: F� ATo Date: a3-/
RE -ROOFS:
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.
Signature of Applicant: Dale:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 hereby affirm under penalty of perjury one of the following three I HAZARDOUS MATERIALS DISCLOSURE
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.
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
permit is issued.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Cade, Sections 25505, 25533, and 25534.
I certify that in the performance of the work for which this permit is issued, I shau
not employ any person in any manner so as to become subject to the Worker's Owner or eu hort% agent:
Compensation laws of Cahfomia. If, after 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
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
cored. 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
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
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records:
Licensed
5 ITEMS OF 5
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 37527022.00
DATE ISSUED.......: 05/23/2012
RECEIPT #.........: BS000016892
REFERENCE ID # ...: 12050179
SITE ADDRESS .....: 18760 TUGGLE AVE
.SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
133.50
---------------
133.50
REFERENCE NUMBER
--------------------
#3389
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------------------------------------ ----------------------------
402 TEMPORARY POWER
OWNER ............:
LAHAV RONEN
ADDRESS ..........:
18760 TUGGLE AVE
CITY/STATE/ZIP
...: CUPERTINO, CA 95014
RECEIVED FROM
....: BAY AREA CUSTOM BUI
CONTRACTOR .......:
CHARLES BALANOJ LIC #
31905
COMPANY ..........:
BAY AREA CUSTOM BUILDERS
INC
ADDRESS ..........:
1002 S DE ANZA BLVD STE
Al
CITY/STATE/ZIP
...: SAN JOSE, CA 95129
TELEPHONE ........:
(408) 446-1200
FEE ID
UNIT QUANTITY AMOUNT PD -TO -DT
--------------------
THIS REC
NEW BAL
-
----------
1BCBSC
-----------------------
VALUATION
----------
300.00 1.00 0.00
1.00
0.00
1BSEISMICR
VALUATION
300.00 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
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
133.50
---------------
133.50
REFERENCE NUMBER
--------------------
#3389
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ------------------------------------ ----------------------------
402 TEMPORARY POWER
��'g CITY OF CUPERTINO
ISD' FEE.ESTIMATOR - BUILDING DIVISION
IMNI
ADDRESS: 18760 Tuggle Ave
APN: BP#:
DATE: 05/23/2012
REVIEWED BY: Sean
'VALUATION: $300
*PERMIT TYPE: Minor Building Permit
BP FEES
PLAN CHECK TYPE: Temporary Power
PRIMMO'
USE:
SFD or Duplex
100
<=600
PENTAMATION 1REAP14
PERMIT TYPE:
WORK
Installation of temporary ower pole
100 am
SCOPE
Sn/)/1/. 1/isp l'te
APPLIANCE / EQUIP TYPE
FEE ID
AMPS
VOLTS
iN••c!l Permit Fee-.
BP FEES
Elec. Permit Fee: IEPERMIT
Service (incl. Temp. Power)
1ERT<200
100
<=600
Plumb. lnsp. Fee-
$44
Permit Fre:
Sn/)/1/. 1/isp l'te
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
COIL M uc/ion Tax.
iIl1/nflll,t'!1'll/l1'L' leer
Work Without Permit? O Yes (F) No
$0.00
Advanced Plunnin•e Fees:
A
Travel Documentation Fee: ITRA VDOC
$44.00
Strong Motion Fee: IBSEISMICR
L "
Wo:h. t •len Ch,:ek
Plumb. Plan, Cheek
Elue. Plon Ch, 14
iN••c!l Permit Fee-.
Plmnh. Penni! Fee:
Elec. Permit Fee: IEPERMIT
OJfra.11rrh. Imp.
Odaa Plumb Insp.Other
F.Icr. ln.rp. $44.00
I p. /".C:
Plumb. lnsp. Fee-
Elcr. hr.rp- Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public {Yorks, Fire, Sanitary Sewer District, School
District. etc). These lees are based on the Dreliminary information available and are onlv an estimate. Contact the Dent for addn 7 info.
FEE ITEMS (Fee Resohition 11-053 tiff 7/1/1 /)
FEE
QTY/FEE
MISC ITEMS
Plun Check Fee:
Supp/. PC 1 ee
Permit Fre:
Sn/)/1/. 1/isp l'te
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
COIL M uc/ion Tax.
iIl1/nflll,t'!1'll/l1'L' leer
Work Without Permit? O Yes (F) No
$0.00
Advanced Plunnin•e Fees:
A
Travel Documentation Fee: ITRA VDOC
$44.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
` SUBTOTALS:
$133.50
$0.00 TOTAL FEE:
$133.50
Revised: 04/01/2012
CUPERTINO
/2 v
GENERAL PERMIT- APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE'AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinD(McuDertino.orD
PLUMBING 0 MECHANICAL I: ELECTRICAL EIMISCELLANEOUS
Ui-71�
MEP
MISC
ADDRESS N-740 760 %�, .l e Ave-
AP""��7-::� -• ,27- o 2-2-
ZOWNEPROJECT
OWNER
R NAME R�)heh C— J a AA v
PHONE�[j�— 92
/ I J I
E-MAIL
STREET ADDRESS `
✓E -
N
CI. STATE, ZIP
FAX
FAX
CONTACT N E
PHONEE-MAB.
STREET ADDRESS
CIN, SCATS, LIP
FAX
WNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME/JQ ^fe� �'K>tI%M h
/T
CENSENUMBER L
q?n6 Lf
LICENSE TYP
BUS. LICA �I (A O15-
I
COFO'ANY NAME/f�
E -MAB. r
b6G�lhL•C0
FAX /I ,, / /
TD yS/6/2.
STREET ADDRESS
002 S pe nZti
CIN, $TATE. IIP
a� G�� C -!2
PHONE
�a-yy6-12O�D
ARCHrrECT/ENG WEER NAME LICENSE NUMBER
BUS. LIC R
CONIPANY NAME
E-MAIL
FAX
STREET ADDRESS
CIN, STATE, ZIP
PHONE
USE OF FD m DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑coM RLTAL
PROJECT IN WBDIAND ❑ YES
URBAN INTERFACE AREA NO
PROJECT IN ❑ YES
FLOOD ZONE IXNO
IS THE BLDG AN ❑ YES
E7CHLER HOME? ArNo
DESCIUMON OF WORK
TOTAL VALUATION:
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property'mvner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is conecL.l have read the Description of Work and verify it is accurate. I agree m comply with all applicable local
ordinances and state laws relating to building construction. 1 onze representatives of Cupertino to enter the above -idem ed propery for inspection puiposes.
Signature of Applicant/Agent:f Date: (') 2 / 12,
SUPPLEMENTAL INFORMATION REQUIRED
'
OFFICE USE ONLY
OVER-THE-COUNTER
I'
Y
❑ EXPRESS
V
U
❑ STANDARD
L
J
❑ LARGE
`
❑ MAJOR
MEP.HfacApp_10JI.dac revised 06/21/11