14060028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10380 STERLING BLVD CONTRACTOR:BLESS ELECTRIC INC PERMIT NO: 14060028
OWNER'S NAME: JALILI MOHSEN H ET AL 10355 STERN AVE DATE ISSUED:06/05/2014
OWNER'S PHONE: 4084996595 CUPERTINO,CA 95014 PHONE NO:(408)499-6595
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
1� TEMPORARY POWER POLE
License Class_ Lic.# ��'( �®
Contractor ,F3 I e g g E i eC y,1'r Date 046 x-66 +f
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. Sq.Ft Floor Area: Valuation:$500
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:37524008.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PE IT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA S LLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Date: —Ab
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source r ula ns er the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
SignatureDate i 4 All roofs shall be ins ed 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino u icipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550 ,2 3 and 25534. /�/
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:V 6-C6
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 CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
GENERAL PERMIT APPLICATION OvE P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION \��
10300 TORRE AVENUE•CUPERTINO, CA 85014-3255 \�'V
(408) 777-3228•FAX(408)777-3333•buildino(a1cupe Lino.org "v i
Lch'
❑PLUbSIIN/G ,( ❑MECHANICAL ❑ELECTRICP.L ❑MISCELrLANEOUS
PROJECT ADDRESS 0 � V V S I Lp f t�'� �V a I APN 4 Z—J UO U
Ov'n' RidpI1E I PHONE E T✓t l
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STREET ADDRESS ,C S 5 S fir V1 �A V r I CITY,STATE,�.V "r l�✓�C) �r A I FAX
coNracr NAME 161r s s =C 1+P�fi�'�'c M C� PHONE Q 6 1 t�')—65 fig(,Ea
STREET ADDRESS CITY,STAM,ZIP FAX
❑ OIAII .t Q M;12,M-BURAER ❑ MWERACST ❑ CO?TMA.CTOR ❑CONTRACTOR AGENr ❑ ARCr cr ❑ENGW=—R. ❑ DE\=PER ❑TEK�. 'T
CONTP.ACTORNA% y S g /'�� LJCENSENU1aE
y 6 a ILICr�SETYPE I BUS.LIC R
COI 2DPA*Y HANE 0 [i E-MAILP0_10CC 1,1 S I Y1 C +^n 4,I.CL FAX
STREET ADDRESS C p I CITY,STATE,ZIP I PHONE
ARChTTECT/ENGINEEER NJAME, LICcT'SE NUI✓BER I BUS.LIC 4
COMPANY NA1J,E E-N.AIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ NIMI-FAM Y PROJECT IN WIIALAND ❑ YES PROJECT Ito* ❑YES IS ThE BLDG AN ❑Ims
BUILDA'G: ❑COYJ.ERCL',L I URBAN D.TiltFACE AREA ❑ NO I FLOOD ZONE ❑No I EMMER HOME? ❑ No
DESCRIPTION Or WORK
TOTALY,'LUATION:
By my signature below,I certify to each of the following: I am flIe prope tyo\\ner or autho aQ on the prop L .11h read thss
application and the information I have provid is c . I have read the Description of Work and verily it is accuratA ree to comply h all applicable local
ordinances and state lams relating to building ons' cti thorize.representatives of Cupertino to enter the above
ntified prope or inspection purposes.
S i�mature of Applicant/Agent: Date: ��—
SUPPL NTAL TFopm-,KTION RE777ED
NEWy _
a
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Win =
IviEPl✓isa4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10380 STERLING BLVD. DATE: 06/05/2014 REVIEWED BY: MELISSA
APN: 375 24 008 BP#: "VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION 1 REAP14
USE: SFD or Duplex PERMIT TYPE:
WORK TEMPORARY POWER POLE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $47
TOTALS: $47.00
Lfci n i'r`rtrr(1,w< Phwlb. Plop C:`hco" Elec.Plan Check 0.0hrs $0.00
hc>c:Jr 1'efnri
Fee: T'lumb. Permit Fee. Elec.Permit Fee: IEPERMIT
{")ti,cr`-ilcrbr. Irrsj- 011wi-1'lumb trap. Other Elec.Insp. 0.0 hrs $47.00
11,�cie. I,rs z l�s�: Tht+rrh, Irzsp. Fee. ?e-
NOTE: This estimate does not include fees due to other Departments('tie.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etG). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff.711113) FEE QTY/FEE MISC ITEMS
t'hM ('hcck
Stippl, PCI tie°
PME Plan Check: $0.00
PME Unit Fee: $47.00
PME Permit Fee: -T-T $47.00
ConsIrv("'tion Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes (E) No $0.00
,1rir'r:r�zt't�cf z'lc'r�rrtiYt� I'cseS:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
1 6.1,01k` 1 $186.50 $0.00 TOTAL FEE: $186.50
Revised: 04/01/2014