15050049 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20888 FARGO DR CONTRACTOR:SIMON ZHANG PERMIT NO: 15050049
OWNER'S NAME: LIU YOUZHONG AND ZHAO WEIYING 18488 PROSPECT RD DATE ISSUED:05/08/2015
OWNER'S PHONE: 4084621188 SARATOGA,CA 95070 PHONE NO:(408)887-0591
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E]
INSTALL TEMPORARY POWER
License Class , Lic.# U /
Contractor V,r Date
I hereby affirm that I am licensed under th 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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$500
lhwe 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:32630116.00 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 DAY 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 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 AS
granting of this permit. Additionally,the applicant understands and will compl Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. �-----
RE-ROOFS:
Signature 7i - Date #jo 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 25505,25533,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 CONSTCTION LENDING AGENCY
RU
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 ® EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION o
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O�
CUPERTINO (408)777-3228• FAX(408)777-3333•building a().cupertino.org
MISC
❑PLUMBING ❑MECHANICAL ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS 20M
4 o V�• APN#
OVrNERNAME V (, �p /� rX� �►f0
I JA PHONr�{„��6�—I'CJ(,� E-MAIL
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STREET ADDRESSV / CITY, STATE,ZIP FAX
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CONTACT NAME I �nPHONE46H9d—o--tq11
E-MAIL
STREET ADDRESS {� CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT _ ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMES LICENSE NUMBER6 LICENSE TYPE BUS.LIC# C
COMPANY NAME v r E-MAIL ` 1 1f��p `, FA J
CITY,STATUE,ZI ,r�•• � C PHONE
STREET ADDRESS Il 0 /t/Y1 LLLSSS
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ARCMTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAM9-Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA Q❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK ev
By my signature XISw I ce mg: I am the property owner or authorized agenttoact on the pe s behalf. I have read this
application and the infor o provided is correct. I have read the Description of Work and verify it is accura e. agree to comply with all applicable local
ordinances and state I mg to bu' traction. 'au ze representatives of Cupertino to enter the above-identified p e for 1ns ecti urposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED ”k, .: oFFCE usE ovLx 3r. .,x
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20888 FARGO DR DATE: 05/08/2015 REVIEWED BY: MELISSA
APN: 326 30 116 BP#: '`VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP14
USE: ' p PERMIT TYPE:
WORK INSTALL TEMPORARY POWER
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1 ERT<200 100 Amps $48
TOTALS: $48.00
Mech.Ptah CheckPlurrrh.Plan CheckElec.Plan Check 0.0 hrs $0.00
:llech. Permit Fee. Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
ntlrer,tech. Insp. (hher•Plumb Insp. Other Elec.Insp. 0.0 hrs $48.00
1-tc:c1:.Insp,Fee: Plumb. Insp. Fee: Elec.Insp.Hee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the prefimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SUPI)/. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tar:
Administrative Fee: /ADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
B1dpStds Commission Fee: IBCBSC $1.00
STBTOTALS $190.50 $0.00 TOTALRE $190.50
Revised: 04/01/2015