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12060021 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20686 RODRIGUES AVE CONTRACTOR:DOLLENS ELEC"IRIC PERMIT NO: 12060021 CORPORATION OWNER'S NAME: ONER KORAY AND YANG EMILY S 3591 PINE RIDGE WAY D:\TE ISSUED:06/0512012 OWNER'SPHONE: 4083731118 SAN JOSE,CA 95127 PlIONE NO:(4118)929-6100 k7 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r L`i'cense Class L10 Lic.4 W ,7376 f� MECH r RESIDENTIAL r COMMERCIAL r Contractor 1, 171 /}i.6C. 1iL62/X rt,Date 1 hereby affirm that 1 am licensed under the provisions of hapmr 9 JOB DESCRIPTION: INSTALLATION 01'9 WI'A'fl IFR41ROOF GFCI PROTECTED (commencing with Section 7000)of Division 3 of the Business&Professions OUTLGIS IN OUTDOOR BBQ COUNTER Cade 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 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 Workers Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sq.F1 Floor Area: Valuation:$350 permit is issued. APPLICANTCERTIFICATION APN Number:35911014.00 Occupancy Typc: 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 cnnstruclion-mid hereby authorize representatives of this city to enter upon(he above mentioned properly for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED iosts,a f)'andkecp harmless tire City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and ex � nay acerae against said City in consequence of the granting this'permit, AOdn ally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all on-point source regula( its per the Cupertino Municipal Code,Section 9.18, " Issued by: � /V �Tli/7 Date: Signature Dale ❑ OWNER-RUILDER DECLARATION RE-ROOF'S: hereby affirm that I am exempt from the Contractor's License Law for one 0f All roofs shall be inspected prior to any rooting material berg installed If a roof is the following Iwo reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property.or my employees with wages as their sole compcnsalion, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature ol'Applivanc Urate: I,as owner of the property,,an exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BF:ITER 1 hereby affirm under penalty of perjury one of the following three declarations: ILC%ARDOUS MATERIALS DISCLOSURE 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 1 have read the hazardous materials requirements under Chapter 6.95 of the perfomance of the work for which this permit is issued. California Health&Safety Code,Sections 25505.25533.and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth& Section 3700 of the Labor Code.fur the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionaliv,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Ba}y Area Air Quxlih'Management District l will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the not employ any person in any manner so as to become subject t0 the Worker's ti ely Code, s 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must r or auto ed rat: furthsynh comply with such provisions or this permit shall be deemed revoked, le' APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that(he above information is I hereby affirm(hat(here is a construction lending agency for the perlonnance of xwrk's correct.I agree to comply with all city and county ordinances and stale Imus relating for which this permit is issued(Sec 3097.Civ C.) to building construction,and hereby authorize representatives of this city t0 enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indeninil'y and keep harmless the City of Cupcnino against liabilities,judgments, Lender's Address costs,and expenses which only accrue against said City in consequence of the granting of this permit,Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all nun-puin(source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand in} plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35911014 .00 DATE ISSUED. .'. . . . . : 06/05/2012 .RECEIPT #. . . . . . . . . : BS000016997 REFERENCE .ID # . . . : 12060021 SITE ADDRESS . . . . ..: 20686 RODRIGUES AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . : OWNER ONER KORAY AND YANG EMILY S ADDRESS . . . . . . . . . . : 20686 RODRIGUES AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JASON R DOLLENS CONTRACTOR . . . . . . . : JASON DOLLENS LIC # 28146 COMPANY . . . . . . . . . . : DOLLENS ELECTRIC CORPORATION ADDRESS 3591 PINE RIDGE WAY CITY/STATE/ZIP SAN JOSE, CA 95.127 TELEPHONE . . . . . . . . : (408) 929-6100 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- lADMIN HOURS 1. 00 41. 00 0. 00 41 . 00 0 . 00 1BCBSC VALUATION 350.00 1. 00 0. 00 1 .00 0. 00 1BREMRECEP NO. OUTLETS 9. 00 44 . 00 0. 00 44 .00 0.00 1BSEISMICR VALUATION 350. 00 0.50 0. 00 0 .50 0.00 1EPERMITFE 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 174 .50 0.00 174 .50 0. 00 METHOD OF PAYMENT 'AMOUNT REFERENCE NUMBER ----------------- --------------- ---- CREDIT CARD 293 . 50 VISA --------------- TOTAL RECEIPT 293 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 512 FINAL HANDI-CAP. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPERTINO Building Department JOB ADDRESS: PERMIT # 126500-7,t OWNER'S NAME: PHONE # -IlfY-ef 7Zef-6100 GENERAL CONTRACTOR: 67q76 FAX # - I am not using any subcontractors: Z6--5k7 — i Date Please check applicable subcontractors -om Tete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO FEE,ESTIMATOR- BUILDING DIVISION ADDRESS: 20686 Rodriguez Ave DATE: 06/05/2012 REVIEWEDBY: Sean APN: BP#: 'VALUATION: $350 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP10 USE: PERMIT TYPE: WORK Installation of 9 Weather-proof GFCI protected outlets in outdoor BBQ counter. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1BREMRECEP 9 # $44 TOTALS: $44.00 loch. Plan Check Plumb. Plein ChevA Elec. Plan Cheek 0.0 1 hrs $0.00 ",,:h. P""uii P"e. I'hmrh. Pcrnw Fac: Elec. Permit Fee: IEPERM/T Orhrr.l/ech. In.p. Other Plumb Insp. Li I Other Dec. Insp. 0.0 hrs $44.00 'x.h. /nep. Pec: Plumb. beep. Fee: tiler.Insp. For: NOTE: This estimate does not includejees due to other Departments(Le. Planning, Public Works, Fire,Sanitary Sewer District,School District,etc). Thesefees are based on'the relimina information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Rcsolulion 11-053'El➢ 7/I/1 11 FEE QTY/FEE MISC ITEMS Plan Chock l•ee- .Suppl. PC Fee PME Plan Check: $0.00 Penni! Fee: .Supp/. /n.cP /'ea PME Unit Fee: $44.00 PME Permit Fee: $44.00 Cnnslruclion Tint: Administrative Fee: ]ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 Advam ed llhaming Fees: Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $174.50 $0.00 TOTAL FEE: $174.50 Revised: 05/0112012 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 950143255 M I CUPERTINO (408)7T7-3228•FAX(408)T77-3333•buildina(G)CUDertino-ora sc ❑PLUMBING D MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROIECTADDRESS APNd _/ / �� Z040& 1 v OWNER NAMEk. P NE0 E-MAO. STREET ADDRESS CITYTF,ZIP H FAX 50AAj'JA10 IC-4. 9 50► CONTACT NAME PHONE q0j E-MAR. ( I 2Z'71 STREET ADDRESS s ljy 'v C-/T ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT,. ❑ CONTRACTOR ❑CONTRACroRAOENT ❑ ARCiBTECT ❑ENGWEER ❑ DEVELOPER ❑TENANT CONTRACTORNA.V¢ LICENS NUMBER LICENSE LLE�ATYPE BUS.CIC B J' G1 n CON(PANY NAME E-MAIL FAX STREET ADDRESS K -7%S7-7 GITY.STAM' -16)7.3 PHONED' -S S ARCI-TrECTIENGINEEA NAME LICENSE NUhQER BUS.LIC p COMPANY NAME E-MAIL FAX STREET ADDRESS CrfY,STATE,ZIP PHONE USE OF SFO.D10'LEX ❑ MULTI-FAMLLY PROTECT IN WILDLAND ❑ YES PROR;CTIN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCLV. � URBAN INTERFACE AAEA NO FLOOD ZONE 5<0 EICHLER HOM11 IVIO DESCRIPTION OF WORK Zl C 5 -rAJ lVf kJ pArIQ Co TOTAL VALUATION: Q RECEIVED BY: By my signature below,I certify to each wing:' [am a property owner or authorized agent to act on the property owner's behalf. I have read this application and the information 1 pro ' oirecL 1 e tad the Description of Work Rad verify it is accurate: I agree to comply with all applicable local ordinances and state laws rola' g to buil ' etim, au 'u re 'ves of Cupertino to enter the above-identitied pmpc:./for inspection purposes. Signature of ApplicanVAgnu Dam: SUPPL MFORMATIONREQUIRED OFFICE USE ONLY m OVER-THE-COUNTER t ❑ EXPRESS u ❑ STANDARD U ❑ LARGE c ❑ NWOR STATS �UuD 377--il MEPMua4pp_1011.doc revised 06/11/11 �rQ I Z.�23�Lo1 Ti