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15090039I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10685 CULBERTSON DR CONTRACTOR: NICE & RIGHT PERMIT NO: 15090039 CONSTRUCTION INC OWNER'S NAME: LIAO CHIEN C AND MA CHUN P O BOX 2285 DATE ISSUED: 09/04/2015 OWNER'S PHONE: 4088610928 CUPERTINO, CA 95015 PHONE NO: (408)861-0928 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ INSTALLATION OF TEMP POWER (100 AMP). License Class- Lic. # 9 D-1 4 Contractor /)%c G R1 f�"7 6lT Gfl,Q %Pate 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: t. 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. 44have and will maintain Worker's Compensation Insurance, as provided for by QSection 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. 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) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: t. 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. 2. 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 permit is issued. 3. 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date Sq. Ft Floor Area: I Valuation: $200 APN Number: 37536033.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: ��/� /�/��i Date: , RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Own e author"zet agent: Date CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional •, CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildin0 CDCUDertino.org /nto �/y3?M I ❑ PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ 1,ESC.ELLANTEOUS PROJECT ADDVS Z04 i ,A➢N -, u- "'AW; i ru fm PHO — _,ON STRE'cT.^DDI �� CITY, ST ZIP F.AX CON�'TACT ' w ff 1� PHO a _ / E MAU, �( r �U 2- b e STREET ADDRE CITY TA E, ZIP / FAX 7 ❑ OWRdrm ❑ ONR\'ER-BunzER ❑ ow..,ERAGENTCONrMACTOR ❑ CONTRACTORAGENT 11 ARCHITECT 13 LNGATEER ElDEVELOPER ❑ Tr.AI�*f CON- 0 NAA yo LICENSE NUMBER LICENSE'PE BUS LIC' COMP. „o _ /� EMAIL Y` FAX STREET ADDRES Q\ CITY ATE, ZIP Cid iNt PHONE 12 Z A-RCHITECTIENGINTER NAME LICENSENUMBEI BUS. LIC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONTE USE OF SFD orDUPLEX ❑ MULTI-F.A ,1aY PRO.cCT LN' WI DLA2.*D ❑ YES PROJECT W ❑ YES BUILDING: COMMERCIAL URBAN NTERF.ACE AREA NO FLOOD ZONE 0410 IS TRE BLDG AN ❑ Y=S hicHLER HOME? NO DESCP.IPTION OF WORK 100 n TOT 4I VALUATION: D �- By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the 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 buil &-611konstruction I authorize representatives of Cupertino to enter the above -id e tified property for inspection purposes. Signature of Applicant/.Agent: Date: SUP IENTALINTFORM ION REQUIRED oFFIc$LSEorLv.,,= OYERTHE-CO 'ITER ❑ STALND:%KD MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION 191 ADDRESS: 10685 Culbertson Dr DATE: 09/04/2015 REVIEWED BY: Sean UNITS APN: BP#: 50 &213 "VALUATION: $200 PERMIT TYPE: Electrical Permit PLAN CHECK TYP : Alteration / Addition / Repair PRIMARY SFD or Du lex USE: p Amps PENTAMATION 1 REAP14 PERMIT TYPE: WORK Installation of temp power 100 amp). SCOPE su py-d. Insp Fe e APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Elec. Permit Fee: /EPERMIT Temporary Power 1 ERT<200 Elec. Insp. 0.0 �hrs$48.00 100 Amps $48 Perinit Fee: su py-d. Insp Fe e PME Unit Fee: $48.00 PME Permit Fee: $48.00 � "�,t.�tt uctiort 7,r:t: -T7 Administrative Fee: IADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, Schoot District eta I These foes are based on the relimina in ormation available and are on1v an estimate. Contact the Dept or addn'l info. FEE ITEMS (Tee Resolution 11-053 Eft 7iU13) FEE QTY/FEE Elec. Plan Check 0.0 1 hrs $0.00 Elec. Permit Fee: /EPERMIT ElOther Elec. Insp. 0.0 �hrs$48.00 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, Schoot District eta I These foes are based on the relimina in ormation available and are on1v an estimate. Contact the Dept or addn'l info. FEE ITEMS (Tee Resolution 11-053 Eft 7iU13) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 Perinit Fee: su py-d. Insp Fe e PME Unit Fee: $48.00 PME Permit Fee: $48.00 � "�,t.�tt uctiort 7,r:t: -T7 Administrative Fee: IADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 IG l'cTitC`t'.td 1Cf�'i;7zYt�? `t'1'g- Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $190.50 $0.00 TOTAL FEE: 1 $190.50 Revised: 07/02/2015