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11090190CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7422 STANFORD PL CONTRACTOR: NEW WORLD BUILDER PERMIT NO: 11090190 OWNER'S NAME: ALAEE DEAN F 2529 STORY RD DATE ISSUED: 09/27/2011 nWNER'S PHONE: 4086210312 SAN JOSE, CA 95122 PHONE NO: (408) 472-3692 -a LICENSED CONTRACTOR'S DECLARATIONF '7 0 �( BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # 1 J r r COMMERCIAL y- Contractor r, Date 2 �� „� T t MECH RESIDENTIAL I hereby affirm that I am licensed under the provisions o Chap er 9 JOB DESCRIPTION: TEMPORARY POWER POLE (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. Sq. Ft Floor Area: Valuation: $400 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. APN Number: 35932025.00 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 PERMIT EXPIRES IF WORK IS NOT 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 AYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAY M LAST CALLED INSPECTION. 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 / C Issued by: Date: 9.18. Signature Date_T(_2_:7-/ ( I RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law 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) 1, as owner of the property, am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS 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. I 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 Health & 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 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. 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 Owner or thorn age •�f p Compensation laws of California. If, after making this certificate of exemption, I ate: 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 AGENCY I hereby affirm that there is a construction lending agency for the performance of %ark's APPLICANT CERTIFICATION 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, r- ' ., and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ng of this permit. Additionally, the applicant understands and will comply I understand my plans shall be used as public records. w i all non-point source regulations per the Cupertino Municipal Code, Section 9.18• Licensed Professional Signature Date 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35932025.00 DATE ISSUED.......: 09/27/2011 RECEIPT #.........: BS000014869 REFERENCE ID # ...: 11090190 SITE ADDRESS .....: 7422 STANFORD PL SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER ALAEE DEAN F ADDRESS ..........: 7422 STANFORD PL CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5815 RECEIVED FROM ....: DEAN ALAEE CONTRACTOR .......: NEW WORLD BUILDER LIC # 31537 COMPANY NEW WORLD BUILDER ADDRESS ..........: 2529 STORY RD CITY/STATE/ZIP ...: SAN JOSE, CA 95122 TELEPHONE (408) 472-3692 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 400.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 400.00 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 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 174.50 --------------- 174.50 VOICE ID DESCRIPTION -------- ---------------------------- 402 TEMPORARY POWER REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION ------------------------------------ GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO, CA 950143255 4 M'R� CUPERTINO []PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS (408) 777-3228 •FAX (408) 777-3333 • building(a�cupertino.or PROJECT ADDRESS APN # `� OWNER NAME � PHONE STREET ADDRESS CITY, STATE, ZIP /�I FAX CONTACT NAME n ,^ d //a PHONE /* ,(��f ZP E-MAIL STREET ADDRESS � � xW CITY. STATE, ZIP /1� - y�� ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMEW�� / �a LI _ SE ERr v Sid E �, BUS. LIC # COMPANY NAME D % E-MAIL FAX STREET ADDRESS CITY, STATE ZIP,-,'/J� O 7 i NE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTE RFACE AREA NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN YES EICHLER HOME? ANO DESCRIPTION OF WORK ��. TOTAL VALUATION: zle6, TRECEIVED 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 building co ction. utho ' representatives of Cupertino to enter the above-identifi d property for inspection pu(poses. Signature of Applicant/Agent: Date: Z S LEMENTAL INFORMATION REQUIRED OFFICE USE ONLY Y OVER-THE-COUNTER ❑ EXPRESS U !7 U ❑ STANDARD ❑ LARGE a ❑ MAJOR 1EPMiscApp_2011.doc revised 06/21/11