10040058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1141 S STELLING RD CONTRACTOR:TR DEVELOPMENT& PERMIT NO: 10040058
CONSTRUCTION INC
NER'S NAME: MR&MRS MARK CHU 6172 BOLLINGER RD STE 151 DATE ISSUED:04/09/2010
OWNER'S PHONE: 4082213589 SAN JOSE,CA 95129 PHONE NO:(408)329-2831
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r— RESIDENTIAL r— COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 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:
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:$1200
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:36222014.00 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: J il r> / Date:
9.18.
zture 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:
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)
I,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. 1 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 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 Own r thor ed:agent;
Compensation laws of California. If,after making this certificate of exemption,I �7 �LPlad—Date:--C��=—��
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 work'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
the above mentioned property for inspection purposes.(We)agree to save
i._ .nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 'fes ,� Licensed Professional
Signature 1C Date411,9
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36222014 . 00
DATE ISSUED. . . . . . . : 04/09/2010
RECEIPT #. . . . . . . . . BS000010139
REFERENCE ID # 10040058
SITE ADDRESS . . . . . : 1141 S STELLING RD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER MR & MRS MARK CHU
ADDRESS . . . . . . . . . . : 1141 S STELLING RD
CITY/STATE/ZIP CUPERTINO CA, CA 95014-5020
RECEIVED FROM MARK CHU
CONTRACTOR . . . . . . . : PAUL YANG LIC # 29369
COMPANY TR DEVELOPMENT & CONSTRUCTION
ADDRESS 6172 BOLLINGER RD STE 151
CITY/STATE/ZIP SAN JOSE, CA 95129
TELEPHONE (408) 329-2831
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
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1BCBSC VALUATION 1, 200 . 00 1. 00 0 . 00 1 . 00 0 . 0
1BSEISMICR VALUATION 1, 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
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CASH 127 . 50
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TOTAL RECEIPT 127. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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402 TEMPORARY POWER
CITY OF CUPERTINO
TEMP POWER
CUPE(�TINO PERMIT APPLICATION FORM
APN #�� Date:
Building Address: z
Owner's Name: Phone #:
Contractor: Phone :
peat I / yat h
Fax #:
Contact: Phone #:
Contractor License #:
Cupertino Business License #:
Job Description:
I � /fi�C'/N ✓o Yom► `�' � o �
Residenti Commercial ❑
Valuation (cost of project): Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>lK Res. Temp Power>IK E 1REAP14
Amps
1 ERT<200 Res. Temp Power<200 E
Amps
1 ERT2001 K Res. Temp Power 200-1 K E
Amps
1 EPERMITFE Electric Permit Issuance E
1 ELCPLNCK Electric Plan Check E
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
/ 1BSEISMICR Seismic Residential B
1
1 TRAVDOC Travel & Documentation B
Fee
Revised 01/07/09