15090051I CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 20791 DUNBAR DR I CONTRACTOR: BLUE BAY REMODELING I PERMIT NO: 15090051 I
I OWNER'S NAME: LI YING AND TANG XUHENG 11651 NOBILI AVE I DATE ISSUED: 09/09/2015 1
OWNER'S PHONE: 6266936877 SANTA CLAP A, CA 95051 PHONE NO: (408)615-0135
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL TEMPORARY POWER
License Class Lic. # of
Contractor ti .p Date
I hereby affirm that I licensed under a 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.
Sq. Ft Floor Area: Valuation: $300
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.
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.
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 sav�
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
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
r. 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.
APN Number: 32630154.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAY IT ISSUANCE OR
180 DA _ LED INSPECTION.
Date:
C� 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.
Owner or authorized nt:
p atec
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
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 • building ftypertino.org
❑ PLU MING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS�o I
I APN # 1 .7 V
C.
3 v l S
OWNER NAME`��
PHONE 3G�?
l
E•MAIL
STREET ADDRESSCITY,
a i6uh B&�'e
STATE, ZIP
Fhb
FAX
CONTACT NAME
PHONE'ftt FQ {
`} rJ �F
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ o A 1-.R ❑ owxER-B=ER ❑ OWNER AGE T
❑ CONTRACTOR ❑ CONTRACTOR AGE2\1T ❑ ARCHITECT ❑ LN(3iI,7EER ❑ DEVELOPER
❑ TENANT
CONTRACTOR K&ME r
LICENSE NUMBERn ( LICENSE TYPE
BUS. LIC n
COMP.A1 Y NAME �� t' n Q
n I EMAIL / I
1. u
Y- �^ dC. (Y�AX
STREET ADDRESS �J A r ,
CITY, STATE, ZIP n
x
PHONE D
�-
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC n
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD . DUPLEX ❑ MULTI -FAMILY . PROJECT IN WILDLAND ❑ YES PROJECT IN
BUILDNO: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE
❑ YES
❑ NO
IS THE BLDG AN
EICHLER HOME?
❑ .S
❑ 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 on the pro o i nerrea s
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate, agree to comply with all applicable local
ordinances and state laws relating to bui n. I authorize repres of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: —a Date:
SUPPLEMENTAL INFORMATION REQUIRED
ST )2:rn11
MEP1flsc-4pp_2011.doc revised 06121/11
CITY OF CUPERTINO
W�
FEE ESTIMATOR — BUILDING DIVISION
imlADDRESS:
20791 DUNBAR DR
DATE: 09/09/2015
REVIEWED BY: MELISSA
UNITS
APN: 326 30 154
BP#:
*VALUATION: $300
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
Amps
PENTAMATION 1 REAP14
PERMIT TYPE:
WORK
INSTALL TEMPORARY POWER
SCOPE
qppL Insp Fee
APPLIANCE / EQUIP TYPE
FEE ID
?'lamb. Plan Check. FT
QTY
UNITS
BP FEES
Elec. Permit Fee: ]EPERMIT
Temporary Power
1 ERT<200
Other Elec. Insp. 0.0 �s$48.00
100
Amps
$48
Permit Fee:
qppL Insp Fee
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Con.41r•ucliorr Tax:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? Yes e) No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRAVDOC
$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, School
District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution I1-053 E(. 7/1/13)
`tech. Plan CheckF-F
?'lamb. Plan Check. FT
Elec. Plan Check 0.0 hrs $0.00
AJech. Pertnif F'ec,:
Phimb. Permit Fef
Elec. Permit Fee: ]EPERMIT
Od?.er eUecit..Insp.F-1 L
Other Plund) jusp.
Other Elec. Insp. 0.0 �s$48.00
hasp. Fee:
t'trrmh f3'cP. F< �
�` ., ::� ' l ti,
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 addn7 info.
FEE ITEMS (Fee Resolution I1-053 E(. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check .Fee:
S'nppl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
qppL Insp Fee
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Con.41r•ucliorr Tax:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? Yes e) No
$0.00
"01"ctYICCd
A
Travel Documentation Fee: ITRAVDOC
$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:
$190.50
Revised: 07/02/2015