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09110134 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRkSS: 11220 TERRA BELLA DR CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09110134 DATE ISSUED: 11/23/2009 OWNER'S NAME: YUH-SHENG TSUEI PHONE NO: ER'S PHONE: 4088321245 ' LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH f- RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:TEMP POWER PERMIT I hereby affirm that 1 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 Valuation:$500 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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 APN Number:35621007.00 Occupancy Type: 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 Date: with all non-point source regulations per the Cupertino Municipal Code,Section Issued 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 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: Date: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: 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). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three 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. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance Code,Sect on th the Cupertino 5532(a)should Municipal C orhandle er 9.12 matethe rial�th& performance of the work for which this permit is issued. SafeAdditionally,should I use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for this contaminants as defined by the Bay Area Air Quality Management District I will Section 3700 of the Labor Code,for the performance of the work for which this 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 Owner or authorized agent:1 Date: in,�1 l Compensation laws of California. If,after making this certificate of exemption,1 `,11 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION i nify and keep harmless the City of Cupertino against liabilities,judgments, c. ,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 Licensed Professional 9.18. �,r � Signature �--- Date CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg 5 ITEMS OF 5 COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35621007 . 00 DATE ISSUED. . . . . . . : 11/23/2009 RECEIPT #. . . . . . . . . BS000009264 REFERENCE ID # 09110134 SITE ADDRESS 11220 TERRA BELLA DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER YUH-SHENG TSUEI ADDRESS . 11220 TERRA BELL DR CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM YUH-SHENG EDWARD TS CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC- --NEW BAL- _ ---------- ---------- ---------- 0 . 00 --- ------------- 500 . 00 1.00 0 .00 1 . 00 1BCBSC VALUATION 0 . 50 0 . 00 1BSEISMICR VALUATION 500 . 00 0 .50 0 . 00 0 . 00 1. 00 42 . 00 0 . 00 42 . 00 1EPERMITFE FLAT RATE 1. 00 42 .00 0 .00 42 . 00 0 . 00 1ERT<200 UNITS 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 TOTAL PERMIT 127 .50 0 .00 127 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER --------------- -------------------- ----------------- CHECK 127 .50 #892 --------------- TOTAL RECEIPT 127 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------- 402 TEMPORARY POWER CITY OF CUPERTINO TEMP POWER CUPUry S TINO PERMIT APPLICATION FORM APN # ff Date: %112-3 -2,) D Buildin�i - Address: 7e. i�r, C�� y�� c� SM I Owner's Name: Phone #: Contractor: Phone #: f0•--2.S5-- _ ---? L�� S ��' Fax #: Phone #: Contact: S19L Contractor License Cu ertino Business License #: Job Description: Cep I Residential M Commercial Valuation(cost of project): o Type of Construction: / Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>1K E 1REAP14 Amps IERT<200 Res. Temp Power<200 E Amps I ERT2001 K Res. Temp Power 200-1 K E Amps 1 EPERMITFE Electric Permit Issuance E / E 1 ELCPLNCK Electric Pane 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICR Seismic Residential B IT 0C Travel & Documentation B Fee Revised 01/07/09 Community Development 10300 Torre Avenue Cupertino CA 95014 n, Telephone(408)777-3228 Fax(408)777-3333 CITY OF ..,UPEkTINO Buildin De artment JOB ADDRESS: PERMIT #, Q ` / I f L-ya To r Y-t• �P O� �Y• I N,-S N Ts,u Z: ot PHONE # OWNER'S NAME: FAX# GENERAL CONTRACTOR: Pc d-Z�V' I am not using any subcontractors: --------- Date Signature Please check applicable subcontractors and complete the folloEin information: LICENSE # SUBCONTRACTOR BUSINESS NAM 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 er/Contractor Signature Date