12110007 CITY OF CUPERTINO BUILDING PERMIT
RUILDINGADDRESS: 10771 GASCOIGNE DR CONTRACTOR:CIJEN'S CONSTRUCTION 11IiRMITNO: 12110007
COMPANY
OWNER'S NAME: FANG JEFFREY S 10349 LF,OL,%CI'APT 1 DATE ISSUED: 11/02/2012
OWNER'S PHONE: 4088050616 CUPERTINO.CA 95014 PHONE NO:(408)726-2956
-Q' LICENSED CON"FRAC'FORS DIiCLARA'TION BUILDING PERMIT INFO: BLDG [ ELECT (✓ PLUMB r
License Class_ Lie.9 �` 3
//' f 7 MF,CII (_ RESIDENTIAL(_I COMMERCIAL (J
Contractor Y/ &t&a/ Dat
� c l/ 3 ARA212j
hereby affirm that 1 am licensed 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 penally of perjury one of the follmving two declarations:
1 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.FI Floor Area: Valuation:$300
1 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 ANN Number:37531024.00 OccupancYTyPe:
AI'I'LICANI'CER'I'IFICA'1'107J
I certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK ISNOT STARTED
to building consimetion,and hereby authorize representatives of this city to enter
upon the above mentioned propeny 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 D YS FROM ST CALLED INSPECTION.
grans,and expenses which may accrue against said Cil}'in consequence of the '} ��
granting of this permit. Additionally,the applicant understands and will comply /L
wish all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature. Dae _
Rh:ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to may roofing material bcitg installed Ira roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm(hal I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,a owner of the property,or my emplo}'ees with wages as their sole compensation, Signature o(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 BE ITER
construct the project(Sec.7044,Business&Professions Code).
hereby alarm under penally of perjury one of the follmving.three I IAY,ARDOIN MATERIALS DISCLOSURE
declarations: I have raid 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&Safeb'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 Ilealth&
perforn mice 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 1 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 M'the liar Area Air Qualily'Management District I will
i maintain compliance with the Cupertino Municipal Code.Chapter 9.1_and the
permit is issued Ilealth&Safely Cade.Sections 25505,25533,and 25534.
1 certify that in the performance of die 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 Owthorized
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensmion provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. V CONSTRUCTION LENDING AGENCY
I hereby affiran that there is it construction lending agency for the perfornance of work's
APPLICANT'CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and sate that the above information is Lender's Name
correct.I agree to comply with all city and count}'ordinances mid state Imes relating
to building construction,and hereby authorize represenatives of this city to aver 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,
costs,and expenses which may accrue against said City in consequence of the ARCI I ITECI"S DECLARA'T'ION
granting 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 Profemiomd
Signature Date
X21 1 vcW —j
GENERAL PERMIT APPLICATION M E P
C COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 950143255 A I _
SC
CUPERTINO (406) 777-3228 • FAX(408)777-3333 • buildina5cuoerino.oro '\e('
❑PLUMBING ❑NECF-kMCAL ❑cLECT 1CAL ❑viSCELLPNEOUS
FROJECTADDRESS/077/A �GOC�'/N� IAPNa 3-7 c:5 y
\/ awrtFx NAME ZU 4'�.VA} Kl7�v /I t) PRONE �Op' D� E-MAIL '�I{Id� CQR�J C
ST FLEET ADDRESS CITY, STAT ZIP FAX
CONTACT NAME PHONE °-MAJL
S-�=.ADDRESS I CITY.STA it ZIP FAX
❑ OWNM- ❑ OWNER-BUILDER ❑ MT AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT, ❑ ARCH=CT ❑ ENGA':--R ❑ DEVELOPER ❑ T'EPUNT
CONTRACTORNAME LICENSE NUNCIR LIC-rSE TYPE I BUS.LIC C
xCOMPANYNAMCU I:`` EICA,- FAX
SNR=- ADDRESS CITY,STAT Z:7 PHONE
ARCH]ECTIINGWEER.NAME I LICENSE NUMBER. I BUS.LC N
COMPANY NAME' I E.W.IL I FAX
STAEETADDRESS I CITY.STAT IIP PHONE
USE OF ❑SFD v DUPLEX ❑ MULTI-FAMLLY PROJECT IN WI DLAND ❑ YES PROJECT IN ❑ YES LS TIv BLDG AN ❑ YS
BUFLDNG: ❑COMMER I URBAN B.TERFACE AREA ❑ NO I FLOOD ZONE ❑NO MCHLDL lio E ❑NO
DESCRIPTION OF WORK
�! oLt1 Z DLA
X
y/X`
TOTAL VALUATION: �ba RECEIVED BY:
By my signatue below,I certify:o each of ion,:allowing: I as to liMperry owner or auriorized agent to act on the properiy owner's behalf. I have-read this
application and the info.—ation I have provided is CO=CL I have rmd Lie Description,of Wo-3,and vc iY it is aceazic. I tag;ee�o compiy with all applicable local
ardirances and state laws misting to building construction. I zutborize representatives of Cup-mno to enter the above-idcntified proper Eor im. ecdon put,,oscs.
SignatL•z of Apnli=nt/Agent Dam:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
y ❑ OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
V
< ❑ LARGE
❑ NAJOR
MEPMuc4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10771 gascoigne dr DATE: 1 110 212 01 2 REVIEWED BY: larrys
APV; gp#: `VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CIIECK TwE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERM111TTl'PE: 1REAP1
NVORKtem ower ole
SCOPE
APPLIANCE/EQUIP TYPE FEE ID Q'I'1' UNITS BP FEES
Temporary Power 1ERT<200 200 Amps $45
TOTALS: $45.00
Much. Plan Check Plumb. Plan Check Elec. Plan Check 0.0 1 Ins $0.00
Alech.Permit Fee: Plmnh.Pewit Fee: Elec. Permit Fee: 1EPERA-fIT
Orher Afm-h.lace. Other Plumb Insp. Other Elec. Insp. 0.0 hrs $45.00
A-loch.Imp.Fee. Plumb. bap. Fee: Elce.Insp.Fee:
NOTE: This estimate sloes not include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District etc.). These fees are hated on the preliminar3 information available and are only an estimate. Contact the Dept for aildn'I info.
FEE ITEMS (Fee Resohuion 11-053 E(l 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
S1fpl)L PC Fee T 14
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consli-uction Tar:
T 7-
Administrative Fee: 1ADMIN $42.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fecs:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 18CBSC $1.00
SUBTOTALS: 1 $178.50 $0.00 TOTAL FEE: $178.50
Revised: 10/01/2012