15110024A
CITY OF CUPERTINO BUILDING PERMIT
BUILD' G'AbljRk99,;.--401I01 ADRLAN-A AVE
CONTRACTOR: GRAND NEST
PERMIT NO: 15110024
CONSTRUCTION
OWNER'S NAME`-ZH0U,
.,T UE AN]? YU JING
13428 CHRISTINE DR
DATE ISSUED: 11/04/2015
OWNER'S': PAO:N;6�40889 18059
SARATOGA, CA 95070
PHONE NO: (408) 891-8059
DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
Install temporary (100 Amps)
Lideris,
power
,(u
C 0 Date
q
I hereby affikmAhat1 airr licensed under,the provisions of Chapter 9
(commencing ,'With iSecti6i -ofbivision 3 of the Business & Professions
-IL:". ',:1 t
Codeandthatmy4anse ii;in "full iiitice: and effect.
ir.I pp.l.q d" f perjuryperjuryone of the following two declarations:
,oy,
penalty
,ce.,, !cate.o cynsent to' elf -insure for Worker's
hi-��Iaili WII44apii�ain �i f s
:1
COftipensatl0o,,as'pi.,g,yi'ded'f6tbctiorii'3700 of the Labor Code, for the
.,
perfo y eirmit is issued.
. I
Sq. Ft Floor Area:
Valuation: $500
j."
ha a ani I' tann',�Vorker s , Compensation Insurance, as provided for by
APN Number: 32620028.00
Occupancy Type:
S tion 3700 �of fh6T ab&'Co&,+ forth& performance of the work for which this
erm i's`isue
APPLICANT CERTIFICATION
Iceriifythatiha�e"r'6ad'this'.application,d state that the above information is
an
PERMIT EXPIRES IF WORK IS NOT STARTED
correct.- I Agree ' tiYoomply. With all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to buildQ.'pau't u8ii6njaud hereby authorize representatives of this city to enter
uponithe py,�;p9gt!0nibidpT6pek1for inspection purposes. (We) agree to save
ifyandke9p1_dpnlessJh6 City Cupertino against liabilities, judgments,
inde ffin 6 6 f
'.;rU 6 against
180 DAYS FROM LAST CALLED INSPECTION.
costs iiandidxpens"�r. pjnayacc said City inconsequence of the
1 �11 � .,I ". 'applicant
by: Date: 114-
,,
'Additi6' ally,'the understands and will comply
graunti �'df n,
=Issued
with -all, n9,Q.7P9Jnt1' u eg�latioris per the Cupertino Municipal Code, Section
:r i
f?
RE -ROOFS:
I be inspected prior to any roofing material being installed. If a roof is
All roofs shall
9.18
Signature yet
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
L 0" DECLARATION
FR -B ILDER
1h
I here I ilgmexempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the fol!o*ing*o teasims.1,N
1, agipwrie.k"of ih6Tfter't` employees with wages as their sole compensation,
y�.orlrny,erni oye
ALL ROOF COVERINGS TO BE CLASS "All OR BETTER
the will th• structure is riot intended or offered for sale (Sec.7044,
w 9.
J I
Business.& fi Ciode),';jlt
,Flpr�o d0siobs
asibwhet of th'dioii6oerty,� Arn, exclusively contracting with licensed contractors to
': . .,I. It, :.
HAZARDOUS MATERIALS DISCLOSURE
. 11;ill - , k�j� � , .
construct the 'project '(S6c:704�4,':Business Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
ii
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
pe'rjury one of the following three
I hereby affliriniiinAifp'einalt; of,perjury
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
a
decly
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I h'av6'andiwiliiim'a'int'�a"in.;A��IC-ert icateof Consent to self -insure for Worker's
if
material. Additionally, should I use equipment or devices which emit hazardous
Coihoengiitioii,,Ids:oigVi46d,f6iiby Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
�k; ch this permit is issued.
perf6riiiiince 6 . f thefof�,Ai
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I h!: Worker's Compensation Insurance, as provided for by
or er s
the Health & Safety Code, Sections 25505 25533 and 25534.
sebtidn]3,7Q0 dfthe -4abdr,Cdoe,;for ,the p6rformance of the work for which this
Owner or authorized agent: DateAl-77"
permit,' issuedty
I certify' that mithe .krtbclo`of the work for which this permit is issued, I shall
not employ afty,persibif in ,ily-mainnerso as to become subject to the Worker's
Co mperisaitiondj,, s'# If; `after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become su 'I� orkWs Compensation provisions of the Labor Code, I must
itpthT, W
I hereby affirm that there is a construction lending agency for the performance of
forthwithpo Pl� w such provisions or this permit shall be deemed revoked.
0
work s for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify "t I 66"r&a&thi§ application and state that the above information is
correct iliagrde,46 cbTplywith all city and county ordinances and state laws relating
to building con�#dction` &46ie6y authorize representatives of this city to enter
.!,�I ii inspection purposes. (We) agree to save
upon, the ahoy �"'doln_ rppeitypri
ffiepi
' " I- - ' I, I I. .. I .
indemnff� and kee�;4 f upertino against liabilities, judgments,
leis�,the;�Cityo C
ARCHITECT'S DECLARATION
costs, and expie"n�'es,7* h' h . may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit.-." diti6iiaily,� ihi applicant understands and will comply
with A noln'-p"6iisgnrce-regulations per the Cupertino Municipal Code, Section
Licensed Professional
9. 8
V
Si tLi I re. 'I Date
T
'
CUPERTINO
GENERAL PERMIT APPLICATION 1151100aL -
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • build! nc cuoertino.org
E PLU,4B NG E MECHANICAL ZrELECTRICAL E ]ASSCELLANrEOUS
PROTECT ADDRESS j n
I .PN1=
39�0 90 09
I Yl Ave
OW-NERNAMiE t.
I PHONE //
r
E-111WL
STREET ADDRESS Qi� 1 ✓qjt e
ROP-11
I CITY, STATE,
4
FAX
(j �j �� /� �
1�
COMIACT NAME
�� v� yl
PHONE,
E-NLSII.
STREn-T.ADDRESS
CITY, STATE, ZIP
FAX
❑ aw.1,m ❑ o A x -.R -BUILDER ❑ 0W.NFR /,GEN -r 2'C01\TRACTOR ❑ CONTP.ACTOR AC= ❑ :SRC?St ECT ❑ ENGINER ❑ DEVELOPER ❑ TENANT
CONTRACT0R N?.h6E LICEN NUh
LICENSE TYPE
I BUS. LIC 4 35k l5
2vP n D
J
COMP.ANY NAIL
I E-Nr.4II
I FAX
0.
STREET ADDRESS
CITY, STATE , ZIP
i
PHONE
c
O
J
ARCHITECTrNGINE,ER NAkM
LICENSE NUMBER
BUS. LIC
COWAXYNAI✓m
E-MAIL
I FAY,
STREET.4DDRESS
CITY, STATE, ZIP
I PHONE
USE OF SFD or DUPLEX ❑ J4U'LTI-F;AA,ZLY PROJECT LN WU-DLAI.'D ❑ YES
I
PROJECT IN YES
IS ifiE BLDG AN [Ell YES
BUILDWO:❑COI r✓T�aRCIAL URBAN LN=- ACB AREA N0
FLOOD ZONE, .0
EICELER HOIVE7 EJNO
DESCPIPTION OF R'ORK FO � r O 1/06)
MIR i
TOTAL VALUATION:
RECEIiEDBl v £ �� i �r `
By my signature below, I certify to each of the following: I am the property owner or authorized aeent to act on the Iloperty 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 lad's relating to buil4ingcons ction. I authorize representatives of Cupertino
to enter the above -identified property for inspection purposes.
�
Signature of Applicant/Agent:
Date: *
SU`PPL ZEN T AL L+�'F ORMATI D
TiFE�OU'�TER zv ix 7
71
z -+:✓ E..,REaSr
N.
art,, _ k-irx 5 Y �✓ t* "":
MEMO=.Y
MEPMiscA.pp_2011.doc remised 06121/11
CITY OF CUPERTINO
FFT ESTIMATOR - BUILDING DIVISION Wa4
liADDRESS:
a
10101 Adriana Ave
QTY/FEE
DATE: 11/04/2015
REVIEWED BY: PAUL
A . PN: 326 20 028
BP#:
*VALUATION: 1$500
*PERMIT TYPE Minor Building Permit
PLAN CHECK TYPE: Temporary Power
—T
("',sk"
SFD, or Duplex
perwit 1."lee.,
PENTAMATION
1REAP14
PERMIT TYPE:
WORK "Jjn�,ta�l
temporary power (100 Amps)
SCOPE.
,
I
In (,'&-ck
A'kch' llermii I Ve"
I'lumb.
0dXr.111xfrnb
Elec. Permit Fee: ]EPERMIT
Other Eke. hNIv. $48.00
NOTE., This estimate does not include fees due to other Departments (Le. Planning, Public Works, tire, Sanitary Se-werutstrict, AYcnool
District, etcj.'These.fees are based on the preliminary information available and are only an estimate. Contact the Dept jor addn't Info.
FEES ITEMS 11 (Fee R I esolution 11-053 Eff. 71LI13
FEE
QTY/FEE
MISC ITEMS
Plcm e'.'hec'k J."ee:',
&uPPL PCFc;e
LJ
perwit 1."lee.,
PME.Unit Fee:.
$48.00
PMIIE''Peiinii Fee:
$48.00
C),),sip 'u'el; ion -71a'
flee:
Work Without Permit? 0 Yes (E) No
$0.00
Adrail , veii 1>1'A!' n*inp!')..'le'es:
Travel Documentation Fee: ITRAVDOC
$48.00
Strom Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Blda istds'Co''mmission Fee: IBCBSC
$1.00
T S
.....
§V�". ..
$145.5 0
$0.00
Revised: 10/01/2015