10080179CITY OF CUPERTINO BUILDING PERMIT
I BUILDING ADDRESS: 20874 HANFORD DR
I OWNER'S NAME: MARTHA KANG
4ER'S PHONE: 4083905127
LICENSED CONTRACTOR'S DECLARATION
License Class Lie. # Y-� CP/
�
e G
Contractor j`' /�''Y� � f�7� `t_ Daate
I hereby affirm that I am licensed under the provisions of Ch ter 9
(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:
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 which this
permit is issued.
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
to building construction, and hereby authorize representatives of this city to enter
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
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.
Signa Date G',6 r :3
�- OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
f, 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,
3usiness & Professions Code)
, as owner of the property, am exclusively contracting with licensed contractors to
:onstruct the project (Sec.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three
leclarations:
have and will maintain a Certificate of Consent to self -insure for Worker's
,ompensation, as provided for by Section 3700 of the Labor Code, for the
erformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this
emit is issued.
certify that in the performance of the work for which this permit is issued, I shall
of employ any person in any manner so as to become subject to the Worker's
ompensation laws of California. If, after making this certificate of exemption, I
come subject to the Worker's Compensation provisions of the Labor Code, I must
�rthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
:ertify that I have read this application and state that the above information is
rrect. I agree to comply with all city and county ordinances and state laws relating
building construction, and hereby authorize representatives of this city to enter
on the above mentioned property for inspection purposes. (We) agree to save
nnify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
anting of this permit. Additionally, the applicant understands and will comply
th all non -point source regulations per the Cupertino Municipal Code, Section
io
;nature Date
CONT1ACTOR: K & M DEVELOPMENT INC PERMIT NO: 10080179
10387 r4IRA VISTA RD DATE ISSUED: 08/26/2010
CUPELTINO, CA 95014 PHONE NO: (408)253-9787
BUILL►ING PERMIT INFO: BLDG r ELECT F PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB D ESCRIPTION: TEMP POWER POLE FOR NEW SINGLE FAMILY
DWELL NG
Sq. Ft F oor Area: Valuation: $1000
APN Number: 32630059.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
18( DAYS FROM LAST CALLED INSPECTION.
Issued by: - F- �
Date:
RE -ROOFS:
All roofs: hall be inspected prior to any roofing material being installed. If a roof is
installed %,ithout first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature :)f Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have rea d the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Cale, Section 25532(a) should I store or handle hazardous material.
Additiona ly, should I use equipment or devices which emit hazardous air
contamins Pits as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or rut r' ed a ent:
� ='Date.
CONSTRUCTION LENDING AGENCY
hereby all irm that there is a construction lending agency for the performance of work's
or which this permit is issued (Sec. 3097, Civ C.)
.ender's Tame
mender's A
ARCHITECT'S DECLARATION
understanc my plans shall be used as public records.
.icensed Professional
CITY OF CUPERTINO
Il FEE ESTIMATOR - BUILDING DIVISION
Ila
APPLIANCE / EQUIP TYPE
ADDRESS:
DATE:
REVIEWED BY:
P, 1
BP FEES
BP#:
VALUATION: j$1,000
-1
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
1. 11,
0 1
I / !,t-)01`11 11?1-1.
PENTAMATION 1REAP14
� PERMIT TYPE:
WORK
TEMP POWER POLE FOR NEW SFDWL
SCOPE
hi "/ I J,
APPLIANCE / EQUIP TYPE
FEE ID
Plu", 1,
P,;,,
QTY
P, 1
BP FEES
Fee: IEPERMT
Temporary Power
I ERT<200
Other Elec. Insp.EE hrs $42.00
1
PME Plan Check:
$42
Pci-iii Fcc:
hi "/ I J,
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$42.007
,5Irong IlohO;l Fcc:
NOTE.- These fees are based on the nreliminary information available and are nniv an Pvfimatp- CantartlhpDont f.,-.dd.11i.f.
FEE ITEMS (Fee Resolution 09-051 Eff 7/1170)
'I'A (h f !0,F (11�1
Plu", 1,
P,;,,
Elec. Plan Check hrs $0.00
P, 1
vi
Fee: IEPERMT
; ri,JiI h, �,,,
Other Elec. Insp.EE hrs $42.00
PME Plan Check:
$0.00
NOTE.- These fees are based on the nreliminary information available and are nniv an Pvfimatp- CantartlhpDont f.,-.dd.11i.f.
FEE ITEMS (Fee Resolution 09-051 Eff 7/1170)
FEE
Q1 Y/FEE
MISC ITEMS
PME Plan Check:
$0.00
Pci-iii Fcc:
hi "/ I J,
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes (F) No
$0.00
Travel Documentation Fee: ITRAVDOC
$42.00
,5Irong IlohO;l Fcc:
Select an Administrative Item
Bldg Stds Conu-nission Fee: IBCBSC
$1.00
SUBTOTALS:
$127.00
$0.00 TOTAL FEE:
$127.00
Revised: 8/17/20J0
CITY OF
CUPEi�TINO
CITY OF CUPFRTINO
TEMP POWER
PERMIT APPLICATION FORM
c
APN# � � vv -HCl
Fee ID
Date z,(vcam
Fee Group
Permit Type
1 ERT> 1 K
Res. Temp Power >I K.
Amps
Building Address:
00,
1ERT<200
Owner's Name:
E
Phone #: / 3
1 ERT2001 K
Res. Temp Power 200.1 K
Amps
Contractor: ,,rte
Phone #: 4d o f 2l?O -51 7
1 EPERMITFE
Electric Permit Issuan;e
Fax #: oto 5' 6
Contact:
Phone #:
-3 FO
Contractor License
E
Cupertino Business License #:
Job Description: r r? ,o� �- = ✓L /-,C. L
Cal Bldg Standards
Commission Fee
B
ALL PERMIT _
TYPES
Residential Cc
mmercial
Valuation (cost of project): , ,
Type of Construction(N/A
oo to::)
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1 ERT> 1 K
Res. Temp Power >I K.
Amps
E
IREAPI4
1ERT<200
Res. Temp Power <20)
Am s
E
1 ERT2001 K
Res. Temp Power 200.1 K
Amps
E
1 EPERMITFE
Electric Permit Issuan;e
E
1 ELCPLNCK
Electric Plan Check
E
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT _
TYPES
1BSEISMICR
Seismic Residential
B
1TR.AVDOC
Travel & Documentat.on
Fee
B
Revised 01 /07/09