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11040124 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21885 OAKVIEW LN CONTRACTOR:PHAN CONSTRUCTION CO PERMIT NO: 11040124 INC OWNER'S NAME: WINSTON SZE 870 S WOLFE RD DATE ISSUED:04/19/2011 4 ER'S PHONE: 4087378323 SUNNYVALE,CA 94086 PHONE NO:(408)737-8323 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class _ Lic.# +� �� r MECH RESIDENTIAL COMMERCIAL Contractor Pift ILG•�l'�MQ�j�L�l-Date 4 4-10tl 1 hereby affirm that I am licensed under the rovisions of Cha ter 9 JOB DESCRIPTION:INSTALL TEMPORARY 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:$150 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32619102.00 Occupancy Type: 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 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 DAYS 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. �.Q Issued by: Date: Signature Wil/ ` Date L 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. 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, 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. 1 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 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 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 -nnify 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 granting of this permit.Additionally,the applicant understands and will comply with 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 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21885 oakview lane. DATE: 04/19/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $150 rPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 REAP14 USE: p PERMIT TYPE: WORK install temp power pole. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT ILIOther Elec.Insp. 0.0 hrs L$42.00 NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info. FEE ITEMS (Fee Resolution 09-051 I ff. 7;'1.-10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $42.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strout Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bid€' Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: 1 $127.50 $0.00 TOTAL FEE: $127.50 Revised: 01/15/2011 CITY OF CUPERTINO 5 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32619102. 00 DATE ISSUED. . . . . . . : 04/19/2011 RECEIPT #. . . . . . . . . : BS000013219 REFERENCE ID # . . . : 11040124 SITE ADDRESS . . . . . : 21885 OAKVIEW LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER WINSTON SZE ADDRESS . . . . . . . . . . : 21885 OAKVIEW LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1145 RECEIVED FROM . . . . : PHOI PHAN CONTRACTOR . . . . . . . : THIEU PHAN LIC # 22212 COMPANY PHAN CONSTRUCTION CO INC ADDRESS . . . . . . . . . . : 870 S WOLFE RD CITY/STATE/ZIP . . . : SUNNYVALE, CA 94086 TELEPHONE . . . . . . . . : (408) 737-8323 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 150 .00 1. 00 0. 00 1.00 0.00 1BSEISMICR VALUATION 150 . 00 0.50 0. 00 0 .50 0.00 1EPERMITFE FLAT RATE 1. 00 42. 00 0.00 42 .00 0. 00 1ERT<200 UNITS 1. 00 42 . 00 0. 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1 . 00 42 .00 0. 00 42 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 127.50 0.00 127.50 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER Building Department City Of Cupertino [is 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: y PERMIT# KA2 Y! 'OWNER'SNAME: 1AIWCAMAPHONE# GENERAL CONTRACTOR: 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 following 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/Contractor Signature Date j C (A z�l GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT+ BUILDING DIVISION 10300 TORRE AVENUE+ CUPERTINO, CA 95014-3255 (408)777-3228+ FAX(408)777-3333+building(aDcupertino.org MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS APN 9 vl f` 1� t O OWNER NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP F CONTACT NAME PHONEE-MAIL 2. 5 O STREET ADDRESS CITY,STATE, ZIP F C .Z+ ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR kONTPLACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME + LICENSE NUMBER LICENSE TYPE BUS.LIC# T�1Y 1 COMPANY NAME E-MAIL FAX +2..x.7 STREET ADDRESS CITY,STATE,ZIP PHONE -?Z ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC k COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,SPATE,ZIP PHONE ISE OF A SFD or Duplex ❑ Multi-Family PROJECT IN WILOLAND PROJECTIN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes )iz No FLOOD ZONE ❑ Yes No DESCRIPTION OF WORK TOTAL VALUATION: R, 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 construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: ;0p SUPPLEMENTAL INFORMATION REQUIRED 2. _ z 7O` 'gam MEPMiscApp 2011.doc revised 03/16/11