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10030168I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20955 ALVES DR CONTRACTOR: GREEN ROCK CONSTRUCTION PERMIT NO: 10030168 'NER'S NAME: MR. & MRS. WONG 12064 CURTNER AVE I DATE ISSUED: 03/29/2010 I t,vVNER'S PHONE: 4087301403 EX LICENSED CONTRACTOR'S DECLARATION c License Class Lic. # / Z 7 3 Z Contractor % (FAQ (l Rr:) C" Date 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. 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. S ; •-nature Zr Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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, Business & Professions Code) I, 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 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. 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 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 forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 1 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 the above mentioned property for inspection purposes. (We) agree to save .inify and keep harmless the City of Cupertino against liabilities, judgments, casts, 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. Date SAN JOSE, CA 95124 PHONE NO: (408) 559-7625 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB F MECH F RESIDENTIAL r– COMMERCIAL I— JOB DESCRIPTION: TEMPORARY POWER POLE Sq. Ft Floor Area: I Valuation: $10000 APN Number: 32630006.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read 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 Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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 Health & Safety Code, Sections 25505, 25533, and 25534. Owner o Z t Date: __% CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32630006.00 DATE ISSUED.......: 03/29/2010 RECEIPT #......... BS000010055 REFERENCE ID # ...: 10030168 SITE ADDRESS 20955 ALVES DR SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER MR. & MRS. WONG ADDRESS 20955 ALVES DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....: MOHAMMAD KHOSHNOUD CONTRACTOR MOHAMMAD KHOSHNOUD LIC # 30955 COMPANY GREEN ROCK CONSTRUCTION ADDRESS 2064 CURTNER AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95124 TELEPHONE (408) 559-7625 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC - NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 10,000.00 ---------- 1.00 ---------- 0.00 1.00 0.00 1BSEISMICR VALUATION 10,000.00 1.00 0.00 1.00 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1ERT2001K UNITS 1.00 63.00 0.00 63.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ---------- 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 149.00 0.00 149.00 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT AMOUNT --------------- 149.00 --------------- 149.00 REFERENCE NUMBER -------------------- MC VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----------------- 402 TEMPORARY POWER :1 "a, CITY OF CUPEf�TINO CITY OF CUPERTINO TEMP POWER PERMIT APPLICATION FORM 10v� U 1 US APN # _ _ Fee ID Date: `-J- Zai—IU Building Address: Permit Type Owner's Name: IERT>1K Phone #: Contractor: 1REAP14 Phone #: /1,,,,),K IERT<200 Res. Temp. Power <200 Amps E Contact: #: Phone �. Contractor License #: 02 -7 Z -- E Cupertino Business License #:^( Job Description: Electric Permit Issuance E Residential Commercial ❑ Valuation (cost of project): Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>1K Amps E 1REAP14 IERT<200 Res. Temp. Power <200 Amps E 1 ERT2001 K Res. Temp Power 200-1 K Amps E 1 EPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B / 1TRAVDOC Travel & Documentation Fee B Revised 01 /07/09 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST ` JOB ADDRESS:i11) SUBCONTRACTOR PERMIT # ��^�� (17 OWNER'S NAME: �(� �j ; \ �'1 �' PHONE # 4-:) `• -� -73-)- ) _ 5 GENERAL CONTRACTOR: BUSINESS LICENSE # % Z 7 ADDRESS: '? .7C. �t <<i l I n i�� r k1c, — CA e6 211' CITY/ZIPCODE: 'f 5O Z 4 *Our municipal code requires all businesses working in the cny io nave a uy vi "'Upul till" .,u3.11�"a NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. �r I am not using any subcontractors: Signature Please check atmlicable subcontractors and complete the following information: 7:7-711 Date Owner / Contractor Signature Date 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 Owner / Contractor Signature Date