12090028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10325 MENI[ART LN CONTRACTOR:DWK CONSTRUCTION PERMITNO: 12090028
OWNFR'SNAME: ZHANGIINGCIIUNANDTAOJUN 18665 LOREE AVE DATE ISSUED:09/052012
OWNER'S PIIONF: 4087025090 CUPERTINO,CA 95014 PHONE NO:(408)996-1186
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT r_1 PLUMB Fj
License Class Lie.q n-,) r_ c r
m''/�• / MECII RESIDENTIAL COMMERCIAL �
Contractor L�/r� LCYISL/� Date
1 hereby affirm(hat lam licensed under the provisions of Chapter 9 3OR 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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$250
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:37515037.00 Occupancy Type:
A IT LICANT CF.RT'I FICATION
Icertify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property 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, 110 DAYS III LAST
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 Issup� G Date:
9.18.
Signature Date
RF:ROOFS:
❑ OIVNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Lar for one of inspection.
the following two reasons:
1,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(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALI.ROOF COVERINGS TO BE CLASS"A"OR BFTTFR
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three DAZARDOUS MATFRIALS 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 Ileallh&
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[lay Area Air Quality Mansgemen(District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code.Sections 25505,25533,and 25534.
1 certify that in the performance of die work for which this permit is issued,I shall
not employ my person in any manner so as to become subject to the Worker's Owner or thorized agent:
Compensation laws of Cali forma. If,after making this certificate of exemption,I Date:O&/--f2
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 AGENCI'
I hereby affirm that there is a construction lending agency for the performance of work's
APPLIC1INf CF.RTIFICAT'ION 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 state laws relating
to building construction,and 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,
costs,and expenses which may accrue against said City in consequence of the AKCI II'I'FCI"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
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10325 MENHART LN DATE: 09/05/2012 REVIEWED BY: MENDEZ
APN: BP#: 'VALUATION: $250
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK TEMP POWER POLE
SCOPE
Alech. Plan Check Plumb.Plan Check Elec. Plan Check 0.0 hrs $0.00
Alech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERAIIT
Other Alech. Insp. Other Plumb Insp. Ll I Other Elec. Insp. 0.0
.Rech.Imp. Fee: Plumb. brsp.Fee: Elce.Insp. Fec:
NOTE: This estimate does not include fees due to other Departments(i.e. Planting, Public Works, Fire,Sanitary Sewer District,School
District.etc.). Thesefees are based on the prelinninaijr information available and are anti,an estimate Contact the De ( or addn'I info.
FEE ITEMS (Fee Resolution 11-053 Ell' 711/1 U FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 E1 amps Electrical
Suppl. PC Fee: I) Reg. Q OT 0.0 T hrs $0.00 $45.00 IERT<200 I Temporary Power
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 1 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: 1ADMIN $42.00 Q
Work Without Permit? O Yes (j) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure 0
Strong Motion Fee: IBSEISdfICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $133.50 $45.001 TOTAL FEE: $178.50
Revised: 07/01/2012
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO, CA 95014-3255 M MIS C
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TOTAL VALUATION: �0 I RECEIVED BY:
By my sig-tam:e below,I c_^y;o each of the ollowing; I am the pmpey owner or au:horiud agent to act on the pm c.y ow cr's behalf I have read chis
a pliradon=d the in:ormzrico I have provided is corect I have:end the Desctiptiou of Work and verify it is acct-ate. I agee a cor,.ply with all applicable local
ordinz:=and stain laws r_!atirg m building esy action, i au3orze rp:ueatacves of Cuper..ne_^:c:LSe zbove-idea'-c pro e.-1:or inspection puPposes.
Signa.'t.:e of Applicant/Agent: Dare:
SUPPLEMENTA-L?N'ORNLATIO QUIRED ICE USE ONLY
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NI fEPMuc4pp_2011.doc revised 06/21/11 '