13010041r CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: -10171 STERN AVE
OWNER'S NAME: KEN LIN
OWNER'S PHONE:
❑ - - - LICENSED CONTRACTOR'S DECLARATION
License Class_ LLic.
fi25/# O2
Contractor WK 677A&h6, Date I C' /3
I 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.
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 thispermit 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
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 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.. y-
Signature - _./ /6,r C, Date—/_3
❑ OWNER -BUILDER DEC
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 (Sec.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).
CONTRACTOR: DWK CONSTRUCTION
18665 LOREE AVE
CUPERTINO, CA 95014
JOB DESCRIPTION:. RESIDENTIAL
TEMP POWER
PERMIT NO: 13010041
DATE ISSUED: 01/07/2013
PHONE NO: (408) 996-1186
COMMERCIAL
11
Sq. Ft Floor Area: I Valuation: $300
I APN Number: 37511064.00 I Occupancy Type:
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, l 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
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 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.
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM T CALLED INSPECTION.
Issued b • Date: /
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 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 255059 25533, and 25534.
Owner or authorized agent: GG'dt9r1. Cs Date:3o Af —�
CONSTRUCTION LENDING AGENCY
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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION.
10300 TORRE AVENUE • CUPERTINO, CA 95014.3255
(408) 777-3228 • FAX (408) 777-3333 • buildinala�cuoertino.ora
MPLUMBING MMECHANICAL M=CIRICAL ❑MISCELLANEOUS
MEP
MISC
PROIECIADDRESS 00/7 51,, ..,, d v
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APN*
OWNER NAME
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CITY, STATE. 7 eKTIM0
FAX
CONTACT NAME _ 4 07XO-5
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STREET ADDRESS ^ ��.L
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❑ OWNER ❑ OwNER-BADDER ❑ OWNER AGENT coNTRAcroR ❑ CANTRACrOR AGENT ❑ ARCIDTECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSENUMBER
LICENSE TYPE
BUS. LIC0
COMPANY NAME
E-MAIL
FAX
STREETADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECLENGB4MNAME
LICENSE NUMBER
BUS.IJC%
COMPANYNAME
E-MAIL
FAX '
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑SPL .DUPLEX ❑ MVLTI•FAMB.Y
BUDDING: ❑COMMERCIAL
PROJECT IN WDDIAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN
FLOOD ZONE
❑ YES
❑ NO
ISTHEBLDGAN ❑ YES
F]CHLDt HOME? ❑ NO
DESCRurnoN OF WORX
a -e
TOTAL VALUATION: 3� ^�
RECEIVED BY
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on thl proirerty owner's beba .. 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 building construction. I authorize representatives. of Cupertino to enter the above-idcnd5ed'property for inspection put�oses.
Signature of Applicant/Agent:.' Date::Zjhl 7 � �
SUPPLEMENTAr7INFORMATION REQUIRED
OFFICE USE ONLY
u
N THE.C'OUNTER
Y❑
EXPRESS
U
U
❑ STANDARD
❑ LARGE
❑ MAJOR
MEPMucApp_1011.doe revised 06/11/11
CITY OF CUPERTINO
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LaADDRESS:
10171 Stern ave -- --- -- -
DATE: 01/07/2013
REVIEWED BY: Mendez
MISC ITEMS
i APN:
BP#:
`VALUATION: $300
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or DU lex
p
Suppl. PC Fee: Q Reg. Q OT
PENTAMATION 1REAP14
PERMIT TYPE:
USE:
$0.00
10
$0.00
WORK
Permit Fee:
SCOPE
Lj
Peck Plan (:'heck I I Plumb. Plan Check
Mede Perini! Fee: Phumb. Penni/ Fee.
Ocher Mech. Insi). ' I Other Plumb Insp.
Mcch. Insp. Fee u Plumb. brsp. Fee:
NOTE: This estimate does not include fees due to other Depart
Planning, Public
Elec. Plan Check 0.0 hrs $0.00
Elec. Permit Fee: IEPERMIT
Other Elec. Insp. 0.0 hrs $45.00
Elcc. Insp. fee:
Sewer District,
uisrec< ma . rnwc cw u.c o....c.. o.. ..•� .�•...»..».
FEE ITEMS (Fee Resolution 11-053 EB' 711112)
........�...,.. _.
FEE
�___._ ___ ._. _
QTY/FEE
__-
MISC ITEMS
Plan Check Fee:
$0.00
F-1-1 amps Electrical
$45.00 IERT<200 I Temporary Power
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl., Insp. Fee -.0 Reg. Q OTp,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
Consin(clion Tax:
Administrative Fee: 1ADM1N
$42.00
O
Work Without Permit? Q Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Travel Documentation Feer ITRA VDOC
$45.00
Strone Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldy Stds Commission Fee: 1BCBSC
$1.00
$133.50
$45.001!
TO`TALFEL7
$178.50
Revised: 10/01/2012