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12050232BUILDING ADDRESS: 10081 JUDY AVE CITY OF-CUPERTINO BUILDING PERMIT _ t I PERNIIT NO: 12050232 O\VNER'S NASIF-: ITONG JBRRY J t] f4i I DATE ISSUED: 05/31/2012 I OWNER'S PHONE.: 4088918059 I, I PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION z License Class -� � L�i�cpq -© �-�=/.7;. ContmcloN` C%,\ ` D, n(r(ilq� :Dam"- 1p 1 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 penally of perjury one of the following two declarations: I have and will maintain a ceniticatc 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 permit is issued. 1 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 permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature / '�`w Date O / ❑ Al OWNER-RUILDF.R DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, as owner of the properly, 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). I hereby affirm under penally of perjury one of the following three 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 permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of Califomia. If, alter making this certificate of exemption, I 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. 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 stale laws relating to building construction. and hereby authorize representatives of this city to enter 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 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, BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: TEMP POWER POLE Sq. Ft Floor Area: I Valuation: $400 APN Number: 37507049.00 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: E16.t) Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material bcug installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicrd Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE: I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth & Safety Code, Section 25532(a) should 1 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 Nlanegement District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: 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 1 understand my plans shall be used as public records. Licensed Professional 6 ITEMS OF 7 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ... :.... : 37507049.00 DATE ISSUED.......: 05/31/2012 RECEIPT #......... BS000016964 REFERENCE ID # ...: 12050232 SITE ADDRESS .....: 10081 JUDY AVE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER .............: HONG JERRY ADDRESS ..........: 10081 JUDY AVE CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: BABEL CONSTRUCTION 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 400.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 400.00 0.50 0.00 0.50 0.00 IEPERMITFE 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 VOICE ID DESCRIPTION VOICE ID. DESCRIPTION -- -------------------------- 402 TEMPORARY POWER