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11050154 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10292 ORANGE AVE CONTRACTOR. PERMIT NO: 11050154 OWNER'S NAME: MIMI TSUI � r�/U�) jj ' DATE ISSUED:05/19/2011 OWNER'S PHONE: 4085305053 , PHONE NO: L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# 2q ?� Z 2i j• MECH RESIDENTIAL COMMERCIAL Contractor I ��- L(V� Date I hereby affirm that I am licensed under the provisions of Chapter 9 '11�, 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: 1 have and will maintain a certificate of consent to self-insure for Worker's k Compensation,as provided for by Section 3700 of the Labor Code,for the T7r performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$500 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. APN Number:35719030.00 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: 5- 9.18. Signature ��"� �— Date S -� 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: I,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). 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 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 Owner o�r.aut�ized agent: Compensation laws of California. If,after making this certificate of exemption,I - _.,�_�. r Date: is ,-t 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"ork'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, —ts,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 I understand my plans shall be used as public records. _a all non-point source regulations per the Cupertino Municipal Code,Section 9.18• Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35719030. 00 DATE ISSUED. . . . . . . : 05/19/2011 RECEIPT #. . . . . . . . - : BS000013500 REFERENCE ID # . . . : 11050154 SITE ADDRESS . . . . . : 10292 ORANGE AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . MIMI TSUI ADDRESS . . . . . . . . . . : 955 E ARQUES AVE CITY/STATE/ZIP . . . : SUNNYVALE, CA 94085 RECEIVED FROM . . . . : FUNG CHI LEE CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 500 .00 1. 00 0. 00 1.00 0. 00 1BSEISMICR VALUATION 500 .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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 127.50 MC --------------- TOTAL RECEIPT 127. 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333•building(ucupertino.or4 MISC CUPERTIINO ❑PLUMBING ❑b1ECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS (D 2-6- /�A e �--��f TAPN# 7 - OWNER NAME /�^ i ^ ( S w� PHONE" S- S-aS-3 E MAn 60 X70 O p Q p G ,pp � STREET ADDRESS ' 0212 V► �/� STATE ZIP / -k 1 pz FAX CONTACT NAME �N T L PHONE 6 r,S� '(T S2/t �E MAIL �p /� STREET ADDRESS /(52 /1 l e CITY,STATE,C('V - rnv i (STT IrD I� FAX �� 01'OWNER 11 OWNER-BUILDER F�❑�OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME '( - / LICENSE �_� SWE ✓ BUS.LIC#O O V CL�1 Fj COMPANY NAME '"FJ' &*Y 'f Yk C �V e- AL' E MAII TJ-fI.!k,Zg /�CBII�j FAX STREET ADDRESS Z a n �A ►H k/ti_� IA�r�Pf C1TY.STATE.ZIPY►A '/(�y/1 /� / 1Q�p > ONF//yR/!i�6 Sd ARCHITECTIENGINEER NAME �v l � Y LICENSE NUMBER V Vt l �o r W�^ BUS.LIC# i�� I COMPANY NAME E-MAI. FAX STREET ADDRESS CITY,STATE,ZIP PHONE ISE OF l!rSFD or Duplex ❑ Multi-Family PROJECT IN WI,DLAND PROJECT IN .STRUCTURE: ❑ Commercial. URBAN INTERFACE AREA ❑ Yes C:-- FLOOD ZONE ❑ Yes Q'tftr— DESCRIPTION OF WORK TOTAL VALUATION: 5� RECEIr6EI�B1G C� 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 Descrip'on of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building constru n. I authorize r sentati es of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: f SUPPLEMENTAL INFORMATION REQUIRED i1 1�r) .. ...-�_...-.___..__._.__ .:_—......_._�.._.cam. MEP MiscApp_2011.doc revised 03/16/11 110,601-5 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10292 ORANGE AVE DATE: 05/19/2011 REVIEWED BY: MENDEZ APN: BP#: "VALUATION: $500 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK TEMP POWER SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $42 TOTALS: $42.001 1 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: lEPERMIT Other Elec.Insp. 0.0 1 hrs 1 $42.00 NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS 0"ee Resolution 09-05/ Istf. 7/11/10) 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 0 No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 i Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $127.501 $0.00 TOTAL FEE.T $127.50 Revised: 04/29/2011 Building Department City Of Cupertino La 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: pZ'4f PERMIT# OWNER'S NAME: H.t PHONE # '4(5"" 6 " 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: V 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