14060027 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10558 STERLING BLVD CONTRACTOR:BLESS ELECTRIC INC PERMIT NO: 14060027
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
Er LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
^ TEMPORARY POWER POLE
License Class_ Lic.# W:�Y0 4
ContractorAless 61P 1� 'L Date 01,0 6,144
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
M) 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:37523030 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 PERMIT 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 DAYS FRO L SPECTION.
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 Date:
granting of this permit. Additionally,the applicant understands and will comply loo
y' —
with all non-point sole do s per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date V 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.
❑ O ER-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(See.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 theupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 5 , 5533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Date: e5
Owner or authorized agent: ..t'll
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 CONST CTION 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 MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255MA `
M I S LC'k
(408) 777-3228•FAX(408)777-3333•buildina(a�cuperlino.org
❑PLUMBING ❑MECHAATICAL ELECTRICAL ❑lUSCELLANTEOUS
PROJECT ADDRESS )0,56 1v 2 I APN# / L�J `J/'•� /l
OWNERNAME M Q K Ste^
STREETADDRESS `O�L C�Pf„ C=' S�TEV'7w'r 11'-'C Q I FAX
CONTACT NAPM a� PHONE y r/ -X14 q-6 5 95 E"'1LAm Pa 10 C, r S i^C 19A YN'C"1, L ,M
STREET ADDRESS cot.-v^ e CITY,STATE, ZIP FAX
ORT'n'"R -13OVI ER-BUIIAER ❑ ORR.'r�..AG`II3i 13 CONTRACTOR ❑CONTRACTORAGENTr 11ARCrIIIECT ❑ENGINEER E] DEVEL.OPER ❑TENAN*f
CONTRACTORNAME (Zl s �^ 'rl �1 LICENSENUIvMER 916 yy ^ LICENSETYP O BUS.LICR
CONgANY NAME V 1 E-"'A'L dib C 111 C �11�(�1'^� FAX
STREET ADDRESS I CTTY,STATE,ZIP I PHONE
ARCHrTBCT/ENGINEER NAME LICENNSE NUMBER I BUS.LIC 4
C01'emyNAME EMAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL ( URBAN INTERFACE AREA ❑ NO I FLOOD TONE ❑NO EMBLERHMIE? ❑ NO
DESCRIPTION OF WORK
`�a r� ��c Y �C�-✓e+�
TOTAL VALUATION: SOD
By my signature below,I certify to each of the following: I am the property o'>Nmer or authorized age e property o-Amer's behalf. I ave r
application and the information I have provi d is rr t. I have read the Description of Work an verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin ons c I uthorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Si--natureofApplicanUAgent: Date: 0 f_cs_
SUPPL NT nIATION REQUIRED00
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NEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10558 STERLING BLVD DATE: 06/05/2014 REVIEWED BY: MELISSA
APN: 375 23 030 BP#: *VALUATION: $500
xPERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP14
USE: p PERMIT TYPE:
WORK TEMPORARY POWER POLE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1 ERT<200 100 Amps $47
TOTALS: $47.00
715
Phuvh. Plan Elec.Plan Check 0.0 hrs $0.00
11liwnh Perrrair Per,: Elec.Permit Fee: IEPERMIT
Other Ahonh/nsrt Other Elec.Insp. 0.0 hrs $47.00
Numb, hasp, Fee: 1,h,(. Imp, I��t>e::
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are only an estimate. Contact the Dept./or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E f 711/13) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
Pei'mil Fee:
PME Unit Fee: $47.00
PME Permit Fee: .$47.00
Tox:
Administrative Fee: 1ADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
tlk`r.13.{`c;Ld r`zi;?tttt'Ig? `des.
Travel Documentation Feer ITRAVDOC $47.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
BldgStds Commission Fee: IBCBSC $1.00
x
$186.501 $0.00 TOTAL FEE: $
186.50
Revised: 04/01/2014