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15040116 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11052 BEL AIRE CT CONTRACTOR:TIMELINE PERMIT NO: 15040116 CONSTRUCTION OWNER'S NAME: LIN AN-CHUNG R AND HSN-MEI A 14401 BIG BASIN WAY DATE ISSUED:04/16/2015 OWNER'S PHONE: 4082537388 SARATOGA,CA 95070 PHONE NO:(408)741-3000 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E] '13 _ INSTALL TEMP POWER License ClassLic.# Contractor I i w�v l ht L �rF�7�Date1 k-J,_ 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:$300 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:35616059 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 PERMIT 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 D D INSPECTI N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, / r costs,and expenses which may accrue against said City in consequence of the ued �b y granting of this permit. dditionally, plicant understands and will comply with all non-point so ce lations r e Cupertino Municipal Code,Section 918. RE-ROOFS: Signature Date��r 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 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) 1,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 'r Qua'ty Management District I performance of the work for which this permit is issued. will maintain compliance with the Cu o unic' al Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti a 5534. Section 3700 of the Labor Code,for theerformance of the work for which this p Owner or authorized ag nt: Dat . 1 15 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 b GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT+BUILDING DIVISION 10300 TORRE AVENUE+CUPERTINO,CA 95014-3255 O (408)777-3228•FAX(408)777-3333•building \L? MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MIS L/LANEOUS PROJECT ADDRESS APN# .v OWNERNAME HONE E-MAIL I 0,j(_ 1 '`C ? STREET ADDRESS ,1 `S CITY, STATE,ZIP FAX PHONE 1i t L CONTACT N C C D ��O. Q Gj q i"GIr1 w C t 2S+ 1- .✓1 a STREET ADDRESS ' CITY,STATE,Z� -;w'� FAX O ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT C�CTOR NAME LICENSE NUMBER rLICFNSETYPE BUS.LIC# a K S el v-1 COMPANY NAME E-MAIL FAX STREET ADDRESS Y,STATE,ZIP PHONE N (1Z> >w o LA 4 L'lk -7 e4 Oqi . L) I , '�vc�v ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF qQ SED or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE NO EICHLER HOME? 4 NO DESCRIPTION OF WORK ri�%4F2� t� .7' -5 2 TOTAL VALUATION: awn51 m..3 By my signature below,I certify to each of the following: IA the property owner or authorized agent to act on t perty owne' ave read this application and the information I have provided is ect. I hav red the Description of Work and verify it is a gree to comply with all applicable local ordinances and state laws relatin tg o buil ' ns ctio a Ize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of ApplicantlAgent: —/ Date: SUPPLEMENTAL INFORMATION REQUIRED " Q � � OFFICE USE t r �y, w ��, ❑MAJOR � � �.F�'��,_-r' MEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 11052 BEL AIRE CT DATE: 04/16/2015 REVIEWED BY: MELISSA APN: 6 059 (0 t' BP#: 14090049 `VALUATION: $300 *PERMIT TYPE: Electrical Per it PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: p PERMIT TYPE: WORK INSTALL TEMP POWER SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $48 777 77 TOTALS $48.00 � 77 : Mech, Plans CheckIMF,= Plumb.Plcrrt('heck Elec.Plan Check 0.0 hrs $0.00 -Meeh. Permil Fee: Plumb.Permit Pee. EIeC.Permit Fee: IEPERMIT Other;Wcch.Insp. Other Plumb Insp. Other Elea Insp. 0.0 hrs $48.00 i�eeh. Irssp.Fee: Plumb. Insp.Fee: Lslec.Insp. Fcee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Theseees are based on the relimina information available and are only an estimate. Contact the Det or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fce: Suppl. PC Fie PME Plan Check: $0.00 Permit.Fee: Suppl. Insp 1f'ee PME Unit Fee: $48.00 PME Permit Fee: $48.00 (,'onstruclion Tax: Administrative Fee: IADMIN $45.00 Work Without Permit? ® Yes (j) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 y $190.501 $0.00 ATO L FEE: $190.50 Revised: 04/01/2015