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11090111 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7.541 ORANGE BLOSSOM DR CONTRACTOR:STEVE WONG PERMIT NO: 11090111 OWNER'S NAME: MR.& MRS.MANH HA 1270 TAINAN CT DATE ISSUED:09/19/2011 0"'`NER'S PHONE: 4084472414 SAN JOSE,CA 95131 PHONE NO: IV LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class _ Lic.#_ J /ryp t r f— MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL TEMP POWER POLE (commencing with Section 7000)of Division 3 of the Business&Professions **SEE NOTES** 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 Sq.Ft Floor Area: Valuation:$480 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36611052.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 D YS FROM LAST CALLED INSPECTION. 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. Issued by: Date: Signature Date 1(�/ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner nth orized ent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ing of this permit.Additionally,the applicant understands and will comply ,A an all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date i CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36611052 . 00 DATE ISSUED. . . . . . . : 09/19/2011 RECEIPT #. . . . . . . . . : BS000014788 REFERENCE ID # . . . : 11090111 SITE ADDRESS . . . . . : 7541 ORANGE BLOSSOM DR SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . MR. & MRS. MANH HA ADDRESS . . . . . . . . . . : 7541 ORANGE BLOSSOM DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5224 RECEIVED FROM . . . . : STEVE WONG CONSTRUC CONTRACTOR . . . . . . . : STEVE WONG LIC # 27645 COMPANY . . . . . . . . . . : STEVE WONG ADDRESS . . . . . . . . . . : 1270 TAINAN CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95131 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1. 00 41. 00 0. 00 41 . 00 0 . 00 1BCBSC VALUATION 480 . 00 1. 00 0 . 00 1 . 00 0.00 1BSEISMICR VALUATION 480 . 00 0. 50 0 . 00 0 .50 0 .00 1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1ERT<200 UNITS 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 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER 0/ � GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildingCcDcupertino.org MISC ❑PLUMBING ❑MECHANICAL IdELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN# gw OWNER NAMEP NE E-MAIL NkU -4tq�- J STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LI ENSE LICENSE TYPE BUS.LIC# .� COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTT-FAMILY PROJECT IN WIIALAND [3YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA r] No FLOOD ZONE ❑NO EICHLER HOME? ElNO DESCRIPTION OF WORK TOTAL VALUATION: 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. J 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-identified property far inspection pu(poses. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER c x ❑ EXPRESS U w ❑ STANDARD U ❑ LARGE c. ❑ MAJOR 1EPMIscApp_2011.doc revised 06/21/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# )OF0 � OWNER'S NAME: PHONE# 0 ( - GENERAL CONTRACTOR: 7 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: Signature -�- Date Please check applicable subcontractors and complete the o lowing information: 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/ nt ctor Signature Date