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12090029CITY OF CUPERTINO BUILDING PERMIT BUILDING.AIIDRESS: 10117STERNAVE CONI'RACfOR: DWK CONSTRUCTION PERMiTNO: 12090029 OWNER'S NAME: SRA LU 18665 LORF,E AVE DATE ISSUED: 09105/2012 OWNER'S PHONE; 6504300136 CUPERTINO. CA 95061 PDONENO:(408) 996-1186 ❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB [, License Class__ Lie.H 6 �O�" / r (— (.J Contmcmr 23 1K 'S/ /GLt!f aOw Datc f O 2-- DI F.CII RESIDENTIAL COMMERCIAL 1 hereby affirm that I am licensed under the provisions of Chapter 9 •10B DESCRIPTION: TEMP POWER POLE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 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 Sq, Ft Floor Area: Valuation: $250 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. APN Number: 37511059.00 Occupancy Type: APPLICANT CERTI FIC TION I certify that I have read this application and stale that the above information is correct- I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK ISNOT STARTED to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save WITHIN 180 D YS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAYS 'R M LAST CALLED INSPECTION. costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicam understands and will comply ' with all non -point source regulations per the Cupertino Municipal Code, Section Iss„�,r y: Date: 9.18. W' Signature 7/r—� Datela?/v' RE -ROOFS: ❑ OWNER-RUILDER DECLARA'T'ION All roofs shall be inspected prior to my roofing material being installed. Ira roof is installed without first obtaining an inspection, I agree to remove all new materials for 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection. the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work, and the structure is not intended or offered for sale (Sce.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO RE CLASS "A" OR BETTER construct the project (Sec.7044, Business R Professions Cade). hereby affirm under penalty of perjury one of the following three HAZARDOUS MATF.RIAI S DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain a Certificate of Consent to self -insure for Worker's California Ilealth S 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 Ifealth S performance of the work for which this permit is issued. Safety Code. Section 25532(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 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the permit is issued Ilcalth & Safety Code, Sections 25505, 25533, and 25534. I certify that in the perfamnance of die 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 Owner or authorize) agent:,{ -- Compensation laws ofCalifornia. If, after making this certificate of exemption,I Date:—�-- become subject to the Worker's Compensmion provisions of the Labor Code, I must 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 stale that the above infomnation is Lender's Name correct. I agree to comply with all city and county ordinances and state laws relating to building construction, mid hereby authorize representatives of this city to enter Lender's Address 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 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 SUBTOTALS: 1 $133.501 $45.001 TOTAL FEE: 1 $178.501 Revised: 0710112012 CUPERTINO GENERAL PERMIT APPLICATION m P P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION -I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 U p p i s c (408) 7Th -3228 • FAX (408) ITE -3333 • building cn. woertlaO no.om m []PLUMBING ❑NECEL4.MiCAL ELF=F_ICAL ❑ e'scaL+Yt0U5 PRC.^ADDRESS - AYN/i .2 OWNER NAME �.fa / NF/ PHO EJS(i)I//' • 0//�C'I 6MAQ- STREET ADDRESS A� - I CITY, SA i a ,� ' ^ 71 / �\ i r I s i7 i. FAX CONTACT NAME l-1(� sIRpl/.�� -terADDRESS iJ ,� LL (..� / �I61sAhz�L��'{n*Dn ,fAr �C � �Az)� F L Ups GT�l6b ❑ OWNER ❑ OWNER -BUILDER, ❑ 0W, AGENT XCONTRA=R ❑ CONRACTOR AL'cirT ❑ AR=E CT ❑ ENGOPM ❑ DEVELOPER ❑TENANT CONRACTOR NAME •,' / 1•I/�IL N G ll[i715E NUMBER ^ li LICENSE TY7 I BUS. LIC a COMPANY NAME .J�CCL(�//P/� �/ /-IgO.yVI EMAIL Jv</i�LJ7%S� • )„{),-qj Q�1 �,JJ,/��`TT S7=ADDRESS Jg s_ 2248E �W , /y�ZI I CRY. 57A(JTT� LP /NV 'M I PHO C'(I� ARC:I—IzCT/ENGLNEZi NAME LICEENSc NI;%maR I BUS. Lic p CoNeA.NY NAME' I E-MAIL FAX STREET ADDRESS C!",STATE ZIP I PHONE USE OF OSM er DUPLD( ❑ MU . FAMILY PROJECT WD.DLU 0 YES PROIECT Bi D YES 9=040!❑9=040!CoN TRCtAL URBAN PTUIFACE AAEA NO FLOOD ZONE ❑ NO I IS Ttic BLDG AN EQD.&2 HOME? ❑ NO DESCRIPTION OF WOR.0 I ' TOTAL VALUATION: #j•�.r1) ' RECEIVED BY: rL , By my signature below, I c^:y to each of the following: I= the propel owner or authorized agent to ac, oo the propcy owner's behalf`. I have read ;his application and the infaruration I have provided is conecL I have ;rad the Description of work and verify it is acca ate. I agree m Comply with all applicable local ordinances and sate laws relating. building consat:czim I authorize r_prescua;;ves of Cuper:[c : ^�T the above-idca '-ed grope.—1 :or inspection pu 'noses. Signat= of Applicant/Agent: ,%� <'i'� Date: (% SUPPLEN ENTAL rNFORMA T N REQUIRED FILE USE ONLY ,y r Y u a U VER-THE-COONTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ NWOR MEPMuc4PP_1011. don revised 06/21/11