12120020 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22390 HOMESTEAD RD CONTRACTOR:BERGELECI'RIC CORP PERMIT NO: 12120020
OWNER'S NAME: HAM JAYNE YEH 5650 W CONI'INELA AVE DATE ISSUED: 12/05/2012
OWNER'S PHONE: 4084461773 LOS ANGELES,CA 90045 PHONE NO:(310)337-1377
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT F PLUMB F
License Class �--1O Lic.# liq 18
"� MECH r RESIDENTIAL r COMMERCIAL r
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Contractor D 'AEIEL�rtL Date t2is-Lis
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: S"IARBUCKS I ST FLOOR-INSTALL ONE 20 AMP
(commencing with Section 7000)of Division 3 of the Business&Professions CONVENIENCE
Code and that my license is in full force and effect. OUTLET
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
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 Sq.Ft Floor Area: Valuation:$800
permit is issued.
APPLICANT CERTIFICATION APN Number:32601027.00 Occupancy Type:
1 certify that I have read this application and stale 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
,,rr Issued by�i i Date/s--S:"
ate:/ l/�
i—�'�
Signature Gt� Dale /Z—S-/Z
I
❑ OWNER-BUILDER DECLARATION
RE:ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons: installed without fust obtaining an inspection,1 agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,1 shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code,Sections 25505,25533,and 25534.
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 Owner ouch_orizetl agent:
forthwith comply with such provisions or this permit shall be deemed revoked.
Date: tZ—SlZ
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
GENERAL PERMIT APPLICATION/ EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING D[VIS ION
(408) TORRE AVENUE•CUP-3333-, CA 950143255 / � ' A
GUPERTINO (408)777-3228• FAX(408)777-3333•buildina(a�cuoertino.oro � v\
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❑PL^U[M[B`ING ❑MECHANICAL ®ELECTRICAL ❑MCEL
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FROIECTADDRESS z2_510 k01PIQ,g-'- x
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STIU=ADDRESS CITY, STATE,ZIP FAX
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C077TACr NAME PHONE E-MAIL
STREETADDRESS CITY,SLATE,ZIP FAX
❑ OWNU ❑ OWNER-BUnZEA ❑ OWNER ADEM ' COMAACTOA ❑OONFRACTOR AGENT ❑ ARCH7ZCT ❑E).'GA A ❑ DZIMOPs72 g❑ TMIXT
COTTRACTORNAME kLLf L LiMSENUMBIaL, UCENS T}T� B�USS.IJC,7 .-.0//
COMPANY NAME l cAriL e tG ,IIc�"� '716-6 6-1 I
STRE-TADD CRY, ATE,ZIP PHONE
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ARCHRECT/ENG3N=NAME UCENSE NUMBER BUS.LIC a
COMPANY NAMEE-MAIL FAX
STREET ADDRESS CRY,SLATE,ZIP - PHONE
USE OF ❑SFD.DUPLEX ❑ MULTI-FAMB.Y PROIECIDiwDDLAND ❑ YES I PROTECT IN ❑YEB ISTHEBLDGM ❑ YES
BLYILDN'G: COM CIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EIOD,III HOME? El NO
DESCRIPTION OF WORK
1hskGll ori deylle�
TOTAL VALUA71ON: RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the propcty owner's behalf I have read this
application and the iafonnation I have provided is correct I bave r ead the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin nstwction I authorize represmtatives of Cupertino to enter the above-identifi dprope;,1 for inspection pni�,oses.
Signature of Applicant/Agent: Date: I Z-15—h Z
S LEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
P 111 —
OVER-THE-COUNTER
❑ EXPRESS
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❑ LARCE
❑ MAJOR
MEPA&t 4pp_2011.doc revised 0621111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 22390 homestead rd 1st floor DATE: 12/05/2012 REVIEWED BY: bobs.
APN: 34a b/ 0a BP#: 'VALUATION: $800
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY Commercial Building PENTAMATION 10EAP10
USE: PERMIT TYPE:
WORK install new branch circuit with new outlet.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Recep/Switch/Outlets 1BREMRECEP 1 # $45
TOTALS: 1 $45.00 � k
�.- ,;MW 5
;F z;
Xlvch. Plan Check Plumb. Plan Check Elec.Plan Check 0.0 hrs $0.00
, led). Permit Fees• Plumb.Permit Fee: Elec.Permit Fee: IEPERMIT
Other Much. Insp. Other Plumb Insp. Other Elea Insp. 0.0 Ins Lwm
Alech. harp.Flc: Plurnb. htsp.Fee: Llet.Insp./Ye:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc.). These fiW are based on the preffinWdrut information available and are only an estimate Contact the Dent for addn'I info.
FEE ITEMS(Fee Resolution 11-053 Bfl LL 2) FEE QTY/FEE MISC ITEMS
Plan Check Fee.:
Suppl, PC Pec
PME Plan Check: $0.00
Pertnit Pee:
Suppl. Insp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tar: 77
Administrative Fee: IADNfIty $42.00
Work Without Permit? ® Yes O No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: iBSE1SMICO $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
r $178.50 $0.00 TOTAL FEE:: $178.50
Revised: 10/01/2012