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10030078 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1138 DERBYSHIRE DR CONTRACTOR:CALIFORNIA HOME PERMIT NO: 10030078 BUILDERS&DESIGN t"'NER'S NAME: HONG ZHANG&SHUXIONG SHI 1775 JUNCTION AVE DATE ISSUED:03/15/2010 ..NER'S PHONE: 4088650523 SAN JOSE,CA 95112 PHONE NO:(408)392-8200 ❑ LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.# MECH r RESIDENTIAL F COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:POWER POLE FOR RESIDENT ADDITION (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:$1000 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. APN Number:36221029.00 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: Date: 9.18. ' Signature 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 1 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 I 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 oru oriz d agent: Compensation laws of California. If,after making this certificate of exemption,I ,. Date: I S - C7 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 u- the above mentioned property for inspection purposes.(We)agree to save nify and keep harmless the City of Cupertino against liabilities,judgments, cv—,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION 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. Licensed Professional Signature _ k Date D CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36221029. 00 DATE ISSUED. . . . . . . : 03/15/2010 RECEIPT #. . . . . . . . . : BS000009932 REFERENCE ID # . . . : 10030078 SITE ADDRESS . . . . . : 1138 DERBYSHIRE DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER HONG ZHANG & SHUXIONG SHI ADDRESS 1138 DERBYSHIRE DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5072 RECEIVED FROM . . . . : DR. HONG ZHANG CONTRACTOR SIMON KREK LIC # 31282 COMPANY CALIFORNIA HOME BUILDERS & DES ADDRESS 1775 JUNCTION AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 392-8200 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 000 . 00 1. 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 000 . 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 #1016 --------------- TOTAL RECEIPT 127 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER CITY OF CUPERTINO TEMP POWER CUPEkTINO PERMIT APPLICATION FORM APN# - Date: Building Address: Rpt;Cu3CR CA Owner's Name: Phone Contractor: �,, o N o M = c�a�` 17 z, �'' Phone #: i�o `�Z - ,�' Z OP Fax #: �`�o � 3`�Z —c�Z- Contact: � Phone #: Contractor License #: Cupertino Business License#: Job Description: Residential Commercial Valuation (cost of project): � �� Type of Construction: /A Quantity Fee ID Fee Description Fee Group Permit Type 1 ERT>1 K Res. Temp Power>1 K 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 r 1BCBSC Cal Bldg Standards B ALL PERMIT l Commission Fee TYPES / 1BSEISMICR Seismic Residential B 1 TRAVDOC Travel & Documentation B Fee Revised 01/07/09 Community Development +. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CfOF Fax(408)777-3333 'rJPE�TINO Buildin De artment JOB ADDRESS: �1M PERMIT # Zvpfff M l ive Ca-zOWNER'SNh �. h PHONE # 2?d 0 X23 GENERAL CONTRACTOR:!S �e k FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 0 Date Owner/Contractor Signature