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11030095 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10450 ANN ARBOR AVE CONTRACTOR:MA_,5v PERMIT NO: 11030095 OWNER'S NAME: LI HUNGWEN&HUNG YING ( � �� DATE ISSUED:03/21/2011 O•'"4ER'S PHONE: 4088982545 PHONE NO: G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r License Class Lic.# SS_2k:k9 I MECH l— RESIDENTIAL COMMERCIAL Contractor ate I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMP POWER POLE-FOR SFDWL 1 STORY W/ATTACHED (commencing with Section 7000)of Division 3 of the Business&Professions GARAGE 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 Section 3700 of the Labor Code,for the performance of the work for hich this Sq.Ft Floor Area: Valuation:$200 permit is issued. APPLICANT CERTIFICATION APN Number:32628017.00 Occupancy Type: I certify that I have read this application and state that the above info ation 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 upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which ay accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. . n the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point sour gu ations p the Cupertino Muni ipal Cf de,Section 9.18. Signature Issued by:� Dater L ( C D � ' C OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,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 declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contamin as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall mainta' co liance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health' Saf o e, ctions 25505,25533,and 2553 . 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 Own r r a thorized agent: forthwith comply with such provisions or this permit shall be deemed revoked. Da APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address cv `, and expenses which may accrue against said City in consequence of the $ g of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION ,A., SII non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32628017. 00 DATE ISSUED. . . . . . . : 03/21/2011 RECEIPT #. . . . . . . . . : BS000012950 REFERENCE ID # . . . : 11030095 SITE ADDRESS . . . . . : 10450 ANN ARBOR AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER LI HUNGWEN & HUNG YING ADDRESS 14770 LIVE OAK LN CITY/STATE/ZIP . . . : SARATOGA, CA 95070 RECEIVED FROM . . . . : KEN G MASUDA 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 200. 00 1. 00 0. 00 1.00 0. 00 1BSEISMICR VALUATION 200 .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•buildingWcupertino.orq MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS JC)1 PROJECT ADDRESS f� APN# `< OWNER NAME PHONE E-MAIL STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHO Zg 6C�10A�t E-MAIL STREET ADDRESS CITY,STA Z FAX ❑ ky, I I In OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT <51ICONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUM n LICENSE✓) E BUS.LIC# t CO ANY ME E L `�� F �•�� 10 STREET ADD CITY, A ,ZIP ": ` 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 PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the following: I aTea perty owner authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I hhe Description Work and verify it is accurate. I gree to o ly with all applicable local ordinances and state laws relating to building construction. Irepresentatives of upertino to enter the abov - e pf 1 for inspection purposes. Signature of Applicant/Agent: Date: ' SUPPLEMENTAL INFORMATION REQUIRED �..,�:oMCE USE ONLY Lf OYER-THE-COUNTER H '�0=EXPRESS ' ;�. ❑ STANDARD ;V LARGE :MAJOR MEPMiscApp_2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION MDDRESS: 10450 ann arbor ave. DATE: 03/21/2011 REVIEWED BY: bobs. PN: BP#: "VALUATION: $200 -� *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Du lex PENTAMATION 1 REAP14 USE: p PERMIT TYPE: WORK temp power pole. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ECT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 1 hrs $0.00 Elec.Permit Fee: /EPERMIT Other Elec.Insp. 0.0 hrs $42.00 NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (F�e.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 0 No $0.00 Travel Documentation Fee: I TRA vDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS:- $127.50 $0.00 TOTAL FEE: $127.50 Revised: 01/15/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 LEE,I Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# t Q3 C) OWNER'S NAME: W PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: ,Q� CITY/ZIPCODE N *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 SUBC TORS HAVE OBTAINED A CITY F C PERTINO BUSINESS LICENSE. t I am not using any subcontractors: l Signa 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 3 11 Owner/Contra or ignature Date