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15080110CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22343 MCCLELLAN RD CONTRACTOR: DIANLI CHEN PERMIT NO: 15080110 CONSTRUCTION OWNER'S NAME: HSUEH PO-JEN AND KONG PO 10181 EMPIRE AVE DATE ISSUED: 08/14/2015 OWNER'S PHONE: 6503039394 CUPERTINO, CA 95014 PHONE NO: (408)888-2898 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F] COMMERCIAL INSTALL TEMPORARY POWER q! License Class_ Lic.# DrdI i �4' i Contractor Dow LE Date 15 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: $800 performance of the work for which this permit is issued. 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: 35705004.00 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 WITIHN 18 T 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 1 LED 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 s � / granting of this permit. Additionally, the applicant understands and will comply sued by: Date: with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. �f RE-ROOFS: Signatur Date J 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. 13OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 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 1, 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 1 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, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: 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 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 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPIJiENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildina(- cugertino.org�� U PLUA,fBIIvG L MECHANICAL W ELECTRICAL U MISCELLANEOUS PROJECT ADDRESS 2.2; ' f I APN <— Q /ti ONVNTER NAMM PHONE S v - Q� E•)✓,-t.IL STREET ADDRESS � � CITY, STATE, ZIP G� FAX CONTACT NAME V I ). � -� / PHONE Aw 6i STREET ADDRESS b ' �` CITY, STATE, ZIP �� CA OV' FAX ❑ OWNc. t ❑ OWNER-BUII-DER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENAI.Z CONTRACTOR N?ME U'a rLj' I LICENSE N 41�al1ER �� /� ` LICENSE TYPE © j ""jy BUS. LIC r COMPANY N.47g , 3 y] j'vj % , end EMAIL com FAX STREET ADDRESS Qt C re / �/f CITY, STATE, ZIP ( 10 PHONE ARCHITECT/ENGLNEER NAh,E LICENSE NUMBER BUS. LIC R COMPANY N.SME E-MAIL, I FAY, STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD u DUPLEX ❑ MULTI-F.A CILY PROJECT LN WILDL.ANTI) ❑ YES PROJECT IN BLTII..DLNG: ❑ COl✓2,=CLAI, I URBAN LN'IERFACE AREA Le N'O FLOOD ZONE ❑ YES x*NO LS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK • ._ . /' i . TOTAL VALUATION: By my signature below, I certify to each of the following- I am the property owner or authorized anent to act o e property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identi d property for inspection purposes. Signature of Applicant/Agent: // „� .� _ Date: OR / /& / -2,0(1 TION REQUIRED MEPMiscApp_2011.doc revised 06121/11 CITY OF CUPERTINO Imo,% i FEE ESTIMATOR - BUILDING DIVISION im,ADDRESS: 22343 MCCLELLAN RD DATE: 08/14/2015 REVIEWED BY: MELISSA UNITS APN: 357 05 004 BP#: `VALUATION: $800 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Amps PENTAMATION 1REAP1 PERMIT TYPE: WORK INSTALL TEMPORARY POWER SCOPE S"r�/SCaI. In:et ['ec APPLIANCE / EQUIP TYPE FEE ID 1'hnrrh, Plan Check QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Temporary Power 1 ERT<200 Other Elec. Insp. 0.0 hrs $48.00 100 Amps $48 Permit Fee: S"r�/SCaI. In:et ['ec PME Unit Fee: $48.00 PME Permit Fee: $48.00 C.:onstruction Tax.- ar:Administrative AdministrativeFee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC 1 $48.00 Stronp, Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Metrirt oto L Thoco foot aro ha.ced on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff 7"7%13) Nfech. Plan Check 1'hnrrh, Plan Check Elec. Plan Check 0.0 1 hrs $0.00 P/an C hecl; FL!cl: Plum!". t Elec. Permit Fee: IEPERMIT Other Alech. Insp 0111cr PlayLi Other Elec. Insp. 0.0 hrs $48.00 Insp. Fee: PME Plan Check: $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Metrirt oto L Thoco foot aro ha.ced on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff 7"7%13) FEE QTY/FEE MISC ITEMS P/an C hecl; FL!cl: Suppl..PC Fee PME Plan Check: $0.00 Permit Fee: S"r�/SCaI. In:et ['ec PME Unit Fee: $48.00 PME Permit Fee: $48.00 C.:onstruction Tax.- ar:Administrative AdministrativeFee: ]ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 .Wvanced Phirming Fec Travel Documentation Fee: ITRA VDOC $48.00 Stronp, Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE: $190.50 Revised: 07/02/2015