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15050126 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10095 BRET AVE CONTRACTOR:HORIZON PERMIT NO:15050126 CONSTRUCTION OWNER'S NAME: HSIAO SUTSEN D AND TSERNG HUAH YEU 35506 ORLEANS DR DATE ISSUED:05/21/2015 OWNER'S PHONE: 4087723138 NEWARK,CA 94560 PHONE NO:(510)673-4769 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL INSTALL TEMPORARY POWER License Class Lie.# q ��i� Contractor 0my Date m , 1 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 erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$400 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:37511023.00 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 URMIT 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 F ED INSPECTIO indemnify and keep harmless the City of Cupertino against liabilities,judgments, _ costs,and expenses which may accrue against said City in consequence of the / granting of this permit. Additionally,the applicant understands and will compl ued by: with all non-point source regulations per t Cupertino Municipal Code,Section 918. 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 25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this - ¢Owner or authorized agen Dater- !"�1 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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 V (408)777-3228• FAX(408)777-3333•building(a�cupertino.org ` V CUPERTINO m I ❑PLUMBING ❑MECHANicAL Ot'LECTRICAL []MISCELLANEOUS PROJECT ADDRESS () © ( 9- APN ^ I ) —D Z ONVNER NAME e PHONE E-MAIL STREET ADDRESS CITY, STATE, P - 4 FAX U6q � UF. �t>vl, . o► CONTACT NAME P ONE E-MAIL , 'f L �3- b Fr► S-00 rna+ M STREET DRESS Q ( oa AU JZ CIrTY, �puzy t St c qX 13ONTTER 11O"AINER-BUILDER El OWNER AGENT Ind"CIO*I ACTOR ElCONTRACTOR AGENT ❑ ARCHITECT ❑ENGINTEER - ❑ DEVELOPER ❑ TENANT CONTRACTOR Ad LIC TSE NUMBER LIC TSE TYPE BUS.LIC COMPANY NAME E-MAIL - FAX I G Al"moo SIP-11 l.'tl t �'i 5 STREET DRE S CITY,STATE, P ONE ARCHPTECT/ENGATEER NAME ^ J LICENSE NUMBER BUS.LIC CON 2ANYNAME v E-MAU, FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD.DUPLEX ❑ MULTI-FAhmy PROJECT IN W=AND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑YES BLTII.DATG: ElCOmmmcLAL URBAN INTERFACE AREA ElNO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act rope 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 .ee to comply with all applicable local ordinances and state laws relating to building cons ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Si nature of Applicant/Agent: Date: Z 1 SUPPLEMENT C TI RE =D k or cEvsEon>i'�h � ��' � OVER THE COnm U�TE x to MEPMiscApp 2011.doc revised 06121111 CITY OF CUPERTINO FEEISTIMATOR-BUILDING DIVISION ADDRESS: 10095 BRET AVE DATE: 05/21/2015 REVIEWED BY: MELISSA APN: 375 BP#: *VALUATION: $400 *PERMIT TYPE:: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION 1 REAP14 USE: SFD or Duplex PERMIT TYPE: i WORK INSTALL TEMPORARY POWER SCOPE APPLIANCE/EQUIP TYPE . FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $48 TOTALS: $48.00 Afech. Plan Check Plumb. Plan Check Elec.Plan Check 0.0 hrs $0.00 :Meeh. Permit Fee: Plumb, Permit Fee: Elec.Permit Fee: IEPERMIT Other Heck Insp, EI—L— Other Plumb Insp. Other Elec.Insp. 0.0 hrs $48.00 1lech.Insp.Fire: Plutub. Lisp. Fee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(Ge 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 for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef. 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Sup121. PC Fee PME Plan Check: $0.00 Permit Fee: S111)p1. Inst?Fee PME Unit Fee: $48.00 PME Permit Fee: $48.00 Construction Tarr: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes Q) No $0.00 Advanced Planning Fees: Travel Documentation Fee: 1TRAVDOC $48.00 i Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Std s Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.50 $0.00 .. = TOTAL FEE: $190.50 Revised: 05/07/2015