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11070103 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10170 AMELIA CT CONTRACTOR:BESTBUILD PERMIT NO: 11070103 CONSTRUCTION INC OWNER'S NAME: LEON LIXIN CHEN 1732 143RD AVE DATE ISSUED:07/15/2011 ER'S PHONE: 5039841131 SAN LEANDRO,CA 94578 PHONE NO:(510)388-5099 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# g S MECH RESIDENTIAL COMMERCIAL Contractor ry—` Date (( I hereby affirm that I a icensed under the provisions of Chapter 9 JOB 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. 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:$300 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:32617013.00 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 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM 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 Issued by Date 9.18. Signature Date 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) I,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). I 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. 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 Ownauthorized agent: Compensation laws of California. If,after making this certificate of exemption,I _Dater 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 murk'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 -unify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the g.....ting 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 6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32617013 . 00 DATE ISSUED. . . . . . . : 07/15/2011 RECEIPT #. . . . . . . . . : BS000014068 REFERENCE ID # . . . : 11070103 SITE ADDRESS . . . . . : 10170 AMELIA CT SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER LEON LIXIN CHEN ADDRESS . . . . . . . . . . : 10170 AMELIA CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BESTBUILD CONSTRUC CONTRACTOR . . . . . . . : ZHONG MING MA LIC # 31451 COMPANY BESTBUILD CONSTRUCTION INC ADDRESS . . . . . . . . . . : 1732 143RD AVE CITY/STATE/ZIP . . . : SAN LEANDRO, CA 94578 TELEPHONE . . . . . . . . : (510) 388-5099 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 300.00 1. 00 0. 00 1. 00 0. 00 1BSEISMICR VALUATION 300 .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 AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 349. 00 #1646 --------------- TOTAL RECEIPT 349. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 :.UPERTINO CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# PHONE# OWNER'S NAME: GENERAL CONTRACTOR: U - BUSINESS LICE SE# ADDRESS: ' t"` v� CITY/ZIPCODE: ' . -7 *Our municipal ode requires all businesses working in the city to have a City of Cupertino business Ii nse. EULED NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) HAVE OBTAINED AHCITY OF CUPERTINO UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS BUSINESS LICENSE. I am not using any subcontractors: Sign tur Date Please check applicable subcontractors and complet the following information: 6/ 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 Date Owner/Contractor Signature GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-32552 MISC (408)777-3228• FAX(408)777-3333• buiidinq(_)C:UDertino.orq CUPERTINO ]PLUMBING NECHANICAL LECTRICAL [:]MISCELLANEOUS PROJECT ADDRESS AFN# OWNER NAME �+ Q PHONE v 3 EMAIL STREET ADDRESS �i CITY, STATE,ZIP FAX CONTACT NAME PHONEC E MAII AA (o _S 'o STREET ADDRESS f�G CITY,STATE, ZIP FAX v ✓� C J ❑ OWNER ElOWNER-BUIIAER ❑ OWNER AGENT VONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 1:1 ENGINEER DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER , /f� LICENSE TYPE 13 BUS.LIC# COMPANY NAME E-MAIL FAX CITY,STATE, PHONE STREET ADDRESS I / , `� b— q— oqq ARCHITECT/ENGINE NAME V LICENSE NUMBER BUS.BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ❑SFD or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: D •D RECEIVED BY: By my signature below, 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.FI 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 for inspection putposes. Signature of Applicant/Agent: _ Date: ST_JPPLENffiVfAf INFORMATION REQUIRED OFFICE USE ONLY VER-THE-COUNTER ❑ EXPRESS Y U w ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMiscApp_201 1.doc revised 06121111