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09100097 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21550 EDWARD WAY CONTRACTOR:DOLLENS ELECTRIC PERMIT NO:09100097 CORPORATION "PER'S NAME: TSU YUAN TSAI 3591 PINE RIDGE WAY DATE ISSUED: 10/15/2009 V wNER'S PHONE: 4087887838 SAN JOSE,CA 95127 PHONE NO:(408)929-6100 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT I— PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:FURNISH AND INSTALL ONE(1)30 AMP 240 VOLT (commencing with Section 7000)of Division 3 of the Business&Professions CIRCUIT Code and that my license is in full force and effect. AND OUTDOOR SUBPANEL TO BACKYARD BESIDE THE DECK. DEC WILL INSTALL GFCI DISCONNECT APPROXIMATE 5FT 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 Sq.Ft Floor Area: Valuation:$1500 permit is issued. APPLICANT CERTIFICATION APN Number:35618020.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued bDatetn – T- a F, -ture Date . OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authoriz d agent: forthwith comply with such provisions or this permit shall be deemed revoked. Date: T 1,CCr1"_/ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name 're above mentioned property for inspection purposes.(We)agree to save i:, nify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address 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 ARCHITECT'S DECLARATION 9.18. (� 1 understand my plans shall be used as public records. Signature �, "v� Date G� Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY $# 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35618020 . 00 DATE ISSUED. . . . . . . : 10/15/2009 RECEIPT #. . . . . . . . . BS000008932 REFERENCE ID # . . . : 09100097 SITE ADDRESS . . . . . : 21550 EDWARD WAY SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER TSU YUAN TSAI ADDRESS 21550 EDWARD WAY CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4765 RECEIVED FROM . . . . : ARI J VALTANEN CONTRACTOR JASON DOLLENS LIC # 28146 COMPANY DOLLENS ELECTRIC CORPORATION ADDRESS 3591 PINE RIDGE WAY CITY/STATE/ZIP . . . : SAN JOSE, CA 95127 TELEPHONE (408) 929-6100 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 500 . 00 1.00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 500 . 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 #2217 --------------- TOTAL RECEIPT 127 .50 091 C)o C 1 CITY OF CUP ERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date: Building Address: 2 i 5 5 o EvwAa-�:' "J Ps 2r( r,V c& Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No X❑ HOA: (Exterior work only) Yes ❑ No ] If yes, provide letter from HOA Owner's Name: Phone#: 75U YUAN 75Pv C��,� �{ Oq - �33 3E Contractor: Phone: 'tc�g -c7?-9 -(,16c) Da _A_aNS (7F-c) Fax: yag - 6o9- 2600 Contractor License#: �3(o 4 3 7 Cupertino Business License#: Contact: Phone: (SRX v,'XL_T7-,NrFax: 4og - 3,f3 - 06/ 9 Residential Commercial Job Description: FvRsi15N AIJp ItN5TP-l- ouC 30 Porn? 2'l0 V. 0uTD�2. Sc �,l�l�cu,L To i kCy_ YPrQO OC_5(4E lite Dec,K OCC W1t-L I N5T7tL-L Cr-C( Dl5CCpNFG1 PRIX S{'{ FE-oM Tk%f Ft:5-Ce ^uQ 15ft -Vqe TCG L-- Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [] ``_ Valuation: Square Footage: Project Size: -Express 0--s-tandard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.bufldit2reen.org Revised 07/14/09 CITY OF CUPERTINO Cin of GENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck Orly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1 BSEISMICO Seismic Commercial B // 1 TRAVDOC Travel & Documentation B 11 1BUSLIC Business License B 5 of 5 RESIDENTIAL PROJECT COVER SHEET Assessor's Parcel Number: Name of owner. S 0 -YAM SAI Project address. �'� C Pu�/�R W fj ��C 1�-1 1rVG CGS �jI y Contact person. �� U ��`'�N Phone. `�`'g 3`t3 ^ 6�0 Fax. Net square footage of lot. s Existing Proposed Square footage: First floor: Second floor: Garage: TOTAL: -e there at least two 10 foot by 20 foot clear spaces inside the garage? y N Is privacy protection planting required for the project? On what floor(s) is work being done? Brief description of work. 1NS�k�-� S` it -'PAPac_ '-ECR tc/rtE VSE A) `R.E�2 Yd4R-D OF sIM-6t� --FAAt,try t1VVS(f Code editions:2008 CBC (Y -N)2008 CFC �N)N)2008 CMC (Y-N) 2008 CPC (Y -N)2008 NEC Effective 1/1/08 ASSESSOR COPY Plan Review Process Work Book Page-8-Revised 1/1/08 RESIDENTIAL PROJECT COVER SHEET Assessor's Parcel Number: —�2- Name of owner. 1 5`-3 -YAM SAI Project address. C QUJ/\(L4) w K� �U�C-F4 1po Contact person. Phone. `I`'g 0(0(9 Fax. Net square footage of lot. i ,%1111111111F Ow Existing Proposed Square footage: First floor: Second floor: Garage: TOTAL: re there at least two 10 foot by 20 foot clear spaces inside the garage? Y N Is privacy protection planting required for the project? On what floor(s) is work being done? Brief description of work. �'S�'��-� S`'F� "T'�1N �- -Paz A-) -P-C�2 Code editions:2008 CBC (Y -N)2008 CFC ( N)2008 CMC (Y-N) 2008 CPC (Y -N)2008 NEC N) APPROVED IN ACCORDANCE WITH THE CITY OF Effective 11/0?ZUpERTINO GODES AND ORDINANCES /)11� c DATES!- -l� (— SIGNIE T ` This set of plans and specific dons#Ak;kS be kept on the fob at all times and it is unlawful to make any changes or alterations on same without written permission from the Building Department,City of Cupe tin The stamping of this plan and specifications SHALL NOT be held to permit or to be an approval of the violation of any provisions , of any City Ordinance or state Law. Plan Review Process Work Book Page-8-Revised 1/1/08 Community Development 10300 Torre Avenue st-, ti Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building Department JOB ADDRESS: PERMIT # 21 �5 0 ►,ow R-o Vr R� c c P E�-t�We <� 9�oly 0 t c�c �:9 OWNER'S NAME: --su- Yu/kti 1-.st-Ni PHONE # o8 , 29, 6100 GENERAL CONTRACTOR: IDoL►-cNS cc n-;�', FAX # 'rt(,8, 2600 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical 00C-L�--N S CL-ccT?-1 C 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 Gci 6-1 Z�o� Owner/Contractor Signature Date