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12120109CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7852 BELKNAP DR CONTRACTOR: AVA CONSTRUCTION PERMIT NO: 12120109 OWNER'S NAME: SUBAGIO PUTU H AND MAR BRENDA M TRU 21060 HOMESTEAD RD APT 216 DATE ISSUED: 12/20/2012 OWNER'S PHONE: 4083156168 CUPERTINO, CA 95014 PHONE NO: (408) 387 -0999 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date 2 I hereby affirm that I am licensed under the provision of Chao/ter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I 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 permit is issued APPLICANT CERTIFICATION 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 Date �_O JIF ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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 (See. 7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project(Sec.7044, Business & Professions Code). I hereby affirm under penalty 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 California. If, after 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 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 Date BUILDING PERMIT INFO: BLDG r- ELECT I— PLUMB I- MECH f— RESIDENTIAL F COMMERCIAL f— JOB DESCRIPTION: INSTALLATION OF TEMP POWER POLE (200 AMP) Sq. Ft Floor Area: I Valuation: $1200 APN Number: 36210042.00 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: Date: C;? 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: 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 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 I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner o rized agent: t7 /�;_> Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of Hork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777 -3228 - FAX (408) 777 -3333 - buildino aecuoertino.org ❑ PLUMBING ❑ MECHANICAL LECTRICAL []MISCELLANEOUS ) , L i 0 ( -(� MEP M Isc PROJECT ADDRESS 79 5—, 2— APN # OWNER NAME ` ^ PH E -MAM SUREEr ADDRESS CITY, STATE, ZIP FAX CONTACT NAME �� Lt LG ' PHONE] MATT STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -B=ER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME U C /1 �IGr16 LICENSE NUMBER LICENSE TYPE _ BUS. LIC # CADWANY NAME 21A U M ` � � j ✓{ �L /eLb C E� FAX STREET ADDRESS 2 (�}/ /' , r ,e LA e 3 1 (/ l V CITY, STP,�TE ��_ C(f , r,` q `3 /� J —� (O 1 ARCHITECT/ENGWEERR NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF KSFD or DUPLEX ❑ MULTI-FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA NO PROJECT IN ❑ YES FLOOD ZONE NO IS THE BLDG AN ❑ YES EICHLER HOME? NO DESCRIPTION OF WORK TOTAL VALUATION: t��V RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to i din construction. I authorize representatives of Cupertino to enter the above - identified pro myy Bor inspection puv�oses. Signature of Applicant/Agent: Date: - PLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY F' v U c OVER- THE - COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MHPMscApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 7852 Belknap Dr. DATE: 12/20/2012 REVIEWED BY: Sean APN: BP #: *VALUATION: $1,200 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: WORK Installation of temporary ower pole 200 amp). SCOPE 1 REAP2J APPLIANCE / EQUIP TYPE FEE ID QTY /FEE QTY UNITS BP FEES Services J 1 ERT <200 200 Amps $45 PME Unit Fee: $45.00 PME Permit Fee: $45.00 Administrative Fee: IADMIN $42.00 Work Without Permit? Yes (F) No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEISMICR NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public works, rue, 3antrary Sewer vtsrrict, acnoot FEE ITEMS (1!•ee Resolution 11 -053 F_ff. T'11122 FEE QTY /FEE MISC ITEMS Plan p x PME Plan Check: $0.00 PME Unit Fee: $45.00 PME Permit Fee: $45.00 Administrative Fee: IADMIN $42.00 Work Without Permit? Yes (F) No $0.00 . t Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg? Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $178.50 $0.00 TOTAL FEE: $178.50 Revised: 10/01/2012 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408 - 777 -3333 JOB ADDRESS: ��i✓ff j=' ;� PERMIT # }% �ll� OWNER'S NAME: .� ✓ ;�� % f p PHONE # GENERAL CONTRACTOR: �� !-may f �� BUSINESS LICENSE # ADDRESS: CITY /ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Z° Signature Da e Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date