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15070191K` CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6630 JOHN DR CONTRACTOR: HOMESTEAD PERMIT NO: 15070191 CONSTRUCTION INC OWNER'S NAME: KO ESTHER M TRUSTEE 10080 STERN AVE DATE ISSUED: 07/27/2015 OWNER'S PHONE: 4083160505 CUPERTINO, CA 95014 PHONE NO: (408) 255-8999 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL 0 INSTALL TEMPORARY POWER (100 AMPS) License Class Lic. # f�/ Contractor / Date ?1.r 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 Sq. Ft Floor Area: Valuation: $500 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 APN Number: 36923011.00 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 FROM LAST CALLED INSP CTI N. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the T6LAO!kb�av"4. granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source re atio er upertino Municipal Code, Section 9.18. �r RE -ROOFS: Signature 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, Sections 25505,2 33 and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorized agent: Date: 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 (5qq0ja l . COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildina(a)cuoertin'c.org ❑ nuio NG ❑ 1,ECHANICAL ELECTRICAL ❑ MISCELLANEOUS PROJECT ADDRESS r I APN N•� ON;, ER AME e v PHONE STREET ADDRESS O r 7Q / I� �a CITY, STATE, ZIP n C3 I FAX CONTACT NAME ^^ PHO;s1 / —� J E- 1vt / q STREET ADDRESSlook � �rn ,- vie CIIY,STATE, ZIP �� �j`n E3Vq o,R ❑ OWI.tRamLDER ElRtT OERAGENT�/��(VOI.TITt4CTOR ❑CO1,7RACTORAGENT ❑ ARCHITECT ❑ ENGn SER ❑ DE-,,-LGPER ❑ TBN.4,N7TT CONTRACTOR N a b42 L1 LICENSE IST 4#t l LICENSE TYPE ;� I BUS. LIC COMPANY 1,1.AA / �•P P d Y'J��I G\C "�M J u / y / D © //Ude CO a FAX��� n� yS ^D-� d S STREET ADDRESS � �� � � ,'► P CITY, STATE, ZIP pi���' Vj 0 PHONE mod' 9•% -IL ARCHITECT/ENGWEEER NAME I° �) r/e LICENSE NTUMBER BUS. LIC n COMPANYN.41JE S� �7P5 E MAIL llj� / ` FAX STREETADDRESS (� CITY, ST TE, Z a Q �� S�SCI�U �t�✓1 ✓m�-e• PH 02\5/46,0 e�% / Ol (5����CL'i7'��/ USE OFSFDorDUPLEX ElMUIL LTI-FA. .PROJECTINWILDLAATD EIYES PROJECTIN ElYES ISTHEBLDGAN ❑ YES BUILDLNG: • ❑ COMNIFRCIAL URBAN ATTERFACE AREA El NO FLOOD ZONES El NO EICHLER HOMaE7 ❑ No DESCRIPTION OF WORK em �aY 0 0 O�l�'►' TOTAL VALU.4TION::RECEIVEDBfi y t'� A.': By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the operty owner's behalf. I have read this application and the information I have provided is correct I hav!A9 the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c o rze representatives of Cupertino to enter the abov - e fledd prop rty for inspection purposes. Signature of Applicant/Agent: /" Dater 7�3 SUPPLEMENTAL D\TOR-MATION REQUIPED �'�' OVER73�-COUNTER �s�C`�? ` A rM'ILI RTEP-1/isc,4pp_2011.doc revised 06121/11 CITY OF CUPERTINO 1500811 FEE ESTIMATOR — BUILDING DIVISION imADDRESS: 6630 JOHN DRIVE AMPS DATE: 07/27/2015 REVIEWED BY: PAUL BP FEES APN: 369 23 011 BP#: I"VALUATION: $500 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Temporary Power 1'R1/l1AR.I' /SE. SFD or Duplex Permit Fee: PENTAMATION PERMIT TYPE: 1 REAP1 WORK Install temporary ower 100 Amps) SCOPE PME Unit Fee: $48.00 APPLIANCE / EQUIP TYPE FEE ID AMPS VOLTS ;9-!eclt. 1'er»21t Fee: BP FEES Elec. Permit Fee: IEPERMIT Temporary Power 1 ERT<200 100 <=600 /'lamb_ Insp. Fee: $48 Permit Fee: Suppl. 117sp Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tax: Adhninistrafh;e Fee: Work Without Permit? O Yes (E) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICR 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 nreliminary information available and are onlv an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E. 7/1/13) Alech. Plan Check Plumb. Plan Clteck Elec. 111cm Check ;9-!eclt. 1'er»21t Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT Other Alech. Insp. Other Plumb Insp, Li Other Iaee. hap. $48.00 ;ileeh. hasp. Fee: /'lamb_ Insp. Fee: Elec. /nsp. Fee: 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 nreliminary information available and are onlv an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E. 7/1/13) FEE QTY/FEE MISC ITEMS Platz Check Fee: Suppl. PC Fee Plumb.A,fech./ E'le c Permit Fee: Suppl. 117sp Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tax: Adhninistrafh;e Fee: Work Without Permit? O Yes (E) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001/ SUBTOTALS: $145.50 $0.00 TOTAL FEE -03 Revised: 07/02/2015