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11030138 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18785 TILSON AVE CONTRACTOR:DWK CONSTRUCTION PERMIT NO: 11030138 OWNER'S NAME: CHING-CHANG FAN&MEGAN SUN 18665 LOREE AVE DATE ISSUED:03/29/2011 OWNER'S PHONE: 6502791509 CUPERTINO,CA 95014 PHONE NO:(408)996-1186 G LICENSED CONTRACTOR'S DECLARATION 4 BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 13 Lic.# o, b�� ``"•'tti!/ MECH RESIDENTIAL COMMERCIAL Contractor rDW I Obite � / I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD 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 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:$800 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:37517034.00 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 b Date: 9.18. Signature_Lc h.. C 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) 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 1 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 or authorized agent: Q Compensation laws of California. If,after making this certificate of exemption,I _ C.�Date:`��--2< —If 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 Hork'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, cosr� qnd expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION gr. of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wit,. 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 . . . . . . . . : 37517034 . 00 DATE ISSUED. . . . . . . : 03/29/2011 RECEIPT #. . . . . . . . . : BS000013027 REFERENCE ID # . . . : 11030138 SITE ADDRESS . . . . . : 18785 TILSON AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHING-CHANG FAN & MEGAN SUN ADDRESS . . . . . . . . . . : 18785 TILSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DWK CONSTRUCTION CONTRACTOR . . . . . . . : JULIE LI HE LIC # 24852 COMPANY . . . . . . . . . . : DWK CONSTRUCTION ADDRESS . . . . . . . . . . : 18665 LOREE AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : (408) 996-1186 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 800 . 00 1. 00 0. 00 1. 00 0. 00 1BSEISMICR VALUATION 800 . 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 ----------------- --------------- -------------------- CHECK 127. 50 #3082 --------------- TOTAL RECEIPT 127. 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 18785 tilson ave DATE: 03/29/2011 REVIEWED BY: pg APN: BP#: 11030138 "VALUATION: $800 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP14 USE: PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT LiOther Elec.Insp. El hrs $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 E . 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: ITRA VDOC $42.00 A Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE: $127.50 Revised: 03/01/2011 l r_ L.% / 3I'� 1 ELIGENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINC3 (408)777-3228• FAX(408)777-3333•building(cDcupertino.org MISC ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL MMISCELLANEOUS PROJECT ADDRESS ! v / SO� APN# J� /1 s / -7 OWNER NAME 1•.y l PH _/_o E-MAIL STREET ADDRESS 'CC CITY, STATE,ZIP /, Sv / FAX CONTACT NAME X ONE ` �� E-MAM ,L DChj �j STREET ADDRE/ CITY.STATE. ZIP T 6 A M FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑VENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAMEu LICENSE NUMLBE' 0� - LICENSE TYPE BUS.LIC# D�A COMPANY NAME i COW-5 TAW-Tr&Al E ILr►I�R�71S/��t C��X( 4,00 •teAl [ 6 —It a6 STREET ADDRESS CITY,STATZLC , og3h _3212/ & / Cq / ARCHITECTIENGINEER 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: -' C.) y U RECEIVED 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: SUPPLEMENTAL INFORMAMN REQUIRED „w, sci' cvsolvl: aory FSE 3Lf1�1 r Ifi � x A `' _ Q<�STANDARD � ea a« , ❑ MA IDit MEPMiscApp_2011.doc revised 03/16/11