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14070041 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10375 S TANTAU AVE CONTRACTOR:"P13�C-�.BE PERMIT NO: 14070041 DETEMM1aED OWNER'S NAME: TAI WONG 'Twf� DATE ISSUED:07/10/2014 OWNER'S PHONE: 4083737730 C(} V h PHONE NO: ❑� LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E] TEMP POWER License Class_ Lie.# Contractor -TWa' Otlk4W 4 Date —7- 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 Vve and will maintain Worker's Compensation Insurance,as provided for by ection 3700 of the Labor Code,for the performance of the work for which this APN Number:37508024 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 O LAST CALLED 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 Issued by: Date: granting of this permit. Additionally,the applicant understands and will comply with all non-point source re tien"er the Cupertino Municipal Code,Section 9 18. G RE-ROOFS: Sign r Date 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. ❑ 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 Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti 25 ,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Date: 7 �� l Owner or authoriz 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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY 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 inconsequence 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 E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 h!'�V (408) 777-322a- ri 8• FAX(408)777-3333•build!noDeno.oro \� ❑ M I PLTJ 1,3 NG - ❑MECHANTTICAL ELECTRIC?J. 01/ISCELLANTEOUS PROs^ DP ESS 7-A-(k ! ( J�I SCI CPN OV INER NAME -;W J�� I PHO\�� -373-77311S I E-.Nit II Srr��R CI-i 1, STATE ZTP.. FAX cry 9 s-a�t�' CONTTACT Nhm I P3011TB =1✓ATS ST-FL—M.4 DDKSS CITY,STAT':,ZIP ( FAX ❑ C-A= ❑ OWNTR-BUII.DER ❑ OVINtKACENT CONTRkCTOR ❑CONTIRACTORl+GENT ❑ P.RCt = ❑ENGn=-?. ❑ D OPER ❑TzN.'1'TT C 0N-1 P.LkCrOR'NAMB ��Q !� I LICr'q 2 3 I LIC SE iYPE 13US.LIC n A- Z COZJ"hNY N 41/ F-JJCAJL FAX !W A G�Ca^� /tvC— -7-w A (pry STREET ADDRESS CI iY,STATE,Zi PHONE —7r 2 f'ti. N ��.c►a-s A- J�Na © : I /3 04 7s ab 4- 3733D ARChTTECT/ENGINFERNAIJ� LICENSENTG�✓3ER I BUS.LICr COMPAW. NAIL E 1Jt II I FAX STREET ADDRESS CRY,STATE,ZIP PHONB tiSE OF ❑SFD or DUPLEX ❑ MULTI-FA.14LY I PROTECT IN WJLDLAND ❑ YES I PROJECT A ❑YES I IS T-BLDG ADI ❑1^cS BUIIDTS'G: p COMI RCL4L URBAN Ih—1--RFACE AREA p NO FLOOD ZONE ❑NO MCI=HOME? ❑ NO . DFSCRIPTION OF WORK r a yl A-AP .4Z _ � TOTFI VPLUATION: �a�. DISE 4: �t- By my sianattre below,I certi�j,to each of the following: I am u,e opt-ty ovrner or authorized agent to act on the property o«mer's behalf. I have read this application and the information I have provided is co 2 read the Description of Work and verify it is accu-ate. I agree to comply vrith all applicable local ordinances and state laws relating to building co etion authorize representatives of Cupe;ino to enter the above-ident�,ed pr p(r};fg-irsrection purposes. Si=nature ofAPplicant'Agent: Date: `D SL E?,IENTAL LNFORNLkTION RE TJ=D Q LEI OL_c TEc`CfJ3R _: , ID � --_u_: NO3.•3ri ORS' �'R= 1�PAlisct.`pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10375 s tantau ave DATE: 07/10/2014 REVIEWED BY: Mendez *VALUATION: $500 APN: BP#: PLAN CHECK TYPE: Alteration / Repair *PERMIT TYPE: Building Permit PENTAMATION 1 REAP 14 PRIMARY SFD or Duplex PERMIT TYPE: USE: WORK temporary ower pole SCOPE Elec.Plan Check 0.0 hrs $0.00 ll m; Perin;tl'e. Elec.Permit Fee: 1EPERMIT Other Elec.Insp. 0.0 hrs $48.00 f,�ti.4T�iLt7YtiJ lYtSn_ Pub c Works, ,Sanitary NOTE: This estimate does notmcl d e the uue juna a iDepmattionts(ii e. leannd are onlh an est m e.eContac the DertDor addn'1 n o� District,etc. . These fees are MISC ITEMS FEE ITEMS (Fee Resolution 11-053 Ef. 7/1113) FEE QTY/FEE Plan Check Fee: $0.00 amps Electrical Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $48.00 IERT<200 Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-((D Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 $0.00 Select allon-Residential Advanced Planning Fee: Building or Structure 0 Travel Documentation Fee: ITRAVDOC $48.00 A Strom Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg,Stds Commission Fee 1BCBSC $1.00 SiJTO�TLS v $142.50 $48.00 = TOTAL FEE: $190.50 .s_ . _. Revised: 07/08/2014