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10040055 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18996 PENDERGAST AVE CONTRACTOR:VINCENT C WONG PERMIT NO: 10040055 OWNER'S NAME: VINCENT C WONG 18996 PENDERGAST AVE DATE ISSUED:04/08/2010 NER'S PHONE: 4089306824 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG T_ ELECT[_ PLUMB License Class Lic.# MECH F_ RESIDENTIAL r- COMMERCIAL Contractor Date JOB DESCRIPTION:TEMP POWER POLE I hereby affirm that I am licensed under the provisions of Chapter 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. Sq.Ft Floor Area: Valuation:$1680 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 anc Type:Occu APN Number:37534039.00 P Y 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 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 1� with all non-point source regulations per the Cupertino Municipal Code,Section Issued by-,,-' Date: 9.18. Signature Date RE-ROOFS: Qq OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is l 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) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,am exclusively contracting with licensed contractors to 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. Safe Code,Section 25532(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Addio,onally,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 conta mants as defined by the Bay Area Air Quality Management District I will mainin compliance with a Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Healt ';& fe Cod ,Se ns 25505,25533,and 25534. I certify that in the performance of the 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 Owner r a th ri d nt Compensation laws of California. If,after making this certificate of exemption,I Date: 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. CON TR CTION LENDING AGENCY I hereby a irm that there is c struction lending agency for the performance of work's APPLICANT CERTIFICATION for whichtis 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 nify an keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and ex nses which may accrue ainst said City in consequence of the granting of th permit. applicant a applicant understands and will comply I understand my plans shall be used as public records. with all non-p int s rce`re la*o s e th Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date L �' CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37534039. 00 DATE ISSUED. . . . . . . : 04/08/2010 RECEIPT #. . . . . . . . . BS000010135 REFERENCE ID # 10040055 SITE ADDRESS 18996 PENDERGAST AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER VINCENT C WONG ADDRESS 18996 PENDERGAST AVE CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM VINCENTE C WONG CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY VINCENT C WONG ADDRESS 18996 PENDERGAST AVE CITY/STATE/ZIP CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- --- 1BCBSC VALUATION 1, 680 . 00 1 . 00 0 . 00 1. 00 0 . 0 1BSEISMICR VALUATION 1, 680 . 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 #1032 --------------- TOTAL RECEIPT 127 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- -------- --------------------------- - ------------------- ----- -- 402 TEMPORARY POWER CITY OF CUPERTINO TEMP POWER CUPERTINO PERMIT APPLICATION FORM APN # Date: x.75 3 v �� AF 9:7 , 20(o Building Address: log Owner's Name: Phone #: 4a cE401!3 ° -q Contractor: Phone #:4AR _ 6,R'2 OWN61e _ (S� (/ Z-DEk Fax #: Contact: Phone #: Contractor License #: Cupertino Business License #: Job Description: Residential Commercial ❑ Valuation (cost of project): Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>IK Res. Temp Power>1K E 1REAP14 Amps IERT<200 Res. Temp.Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K E Amps IEPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICR Seismic Residential B 1TRAVDOC Travel & Documentation B Fee Revised 01/07/09 OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A. V All the work authorized by this permit B. V A portion of the work C. — None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. ✓ All of the work B. — A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be erformed '�uD A&P Ca X171 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Address/City Phone Number Type of work to be Person/Firm performed .......................................................................... I declare under penalty of perjury;hat the abov `�true and correct: 11!ave read and understand the Owner-Builder Information(reve a s*gde). 1! _ Property Owner's Signature: T 1,a0n Date. _ S / 0 C_ C2 Job Address: Permit# An Chan es to the information roVided on this form shall be submitted to the Ci of Cupertino Build Department.